LIBRARY OF CONGRESS. 



Chap... J- .—. Copyright No. 

ShellJ 

_<*>. I 5 

UNITED STATES OF AMERICA. 



PRACTICAL TREATISE 



ON 



MEDICAL DIAGNOSIS 



FOR STUDENTS AND PHYSICIANS. 



BY 



JOHN H. MUSSEE, M.D., 



PKOFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA ; PHYSICIAN TO THE 

PHILADELPHIA AND THE PRESBYTERIAN HOSPITALS; CONSULTING PHYSICIAN TO THE WOMAN'S 

HOSPITAL OF PHILADELPHIA AND TO THE WEST PHILADELPHIA HOSPITAL FOR WOMEN ; 

FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; MEMBER 

OF THE ASSOCIATION OF AMERICAN PHYSICIANS, ETC. 



THIRD EDITION, REVISED AND ENLARGED. 



ILLUSTRATED WITH 253 WOODCUTS AND AS COLORED PLATES 




LEA BROTHERS & CO., 
PHILADELPHIA AND NEW YORK. 



TWO COPIES RECEIVED. 



Library of Congrftt* 
Office of the 

N0V2818PQ 

BegitUr of C«pyr!ffcf* 



^V 



48625 

Entered according to the Act of Congress, in the year 1899, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress, at Washington. AH rights reserved. 



SECOND COPY. 






DOENAN, PRINTER, 
PHILADELPHIA. 



to 



TO THE 



MEMOEI OF MY FATHER 



BENJAMIN MUSSER, M.D 



MY GRANDFATHER 



MARTIN MUSSEE, M.D. 



PREFACE TO THIRD EDITION. 



The appearance of a third edition seems to justify the author's 
convictions expressed in the preface to previous editions concerning 
methods of diagnosis. 

The present issue has been largely rewritten and rearranged. The 
recent advances in methods of diagnosis which have proved to be 
reliable have been added. 

I am indebted to many kind friends for valuable assistance. Dr. 
Joseph Sailer rewrote the chapter on Nervous Diseases, arranging it 
to conform with the body of the book. Dr. William C. Posey wrote 
the section on Diseases of the Eye. Dr. Thomas S. Kirkbride, Jr., 
wrote the pages on the Pictoric Records of Physical Signs, and spared 
neither time nor labor in the preparation of the new plates. Dr. 
"W. S. Smith, of Boston, most kindly revised the section on Sputum, 
making valuable additions. Dr. Fred. H. Howard rendered valuable 
assistance and prepared the index. Finally, I am indebted to my 
secretary, Miss Fannie V. Coe, for valuable assistance rendered while 
the work was passing through the press. 

1927 Chestnut Street, Philadelphia. 



PREFACE TO SECOND EDITION 



Success in treatment requires both accuracy and completeness 
in diagnosis. Partial knowledge of the nature of the case differs 
merely in degree from ignorance, and treatment based on either 
invites chances unjust alike to the patient and to the interests of the 
physician. 

Diagnosis, being a practical art, should be held to include not 
merely the recognition of a disease or a complication of diseases, 
but also a determination of the health-value of the patient. Thus 
in a case of pneumonia not only should the presence of the malady 
be established, but the functional condition of all the organs should 
also be investigated, in order that rational treatment may be pre- 
scribed and a rational prognosis given. In other words, the physi- 
cian should never forget that a patient is a unit, comprising closely 
interacting organs, and that the response to treatment will be satis- 
factory in proportion to its adaptation to the condition of the entire 
organism. After twenty years of experience as a general practi- 
tioner, a hospital physician, and later as a consultant, the writer 
is confirmed in the conviction that success in treatment follows only 
upon diagnosis of the most comprehensive character, and, further- 
more, that the status prcesens should be clear to the physician, not 
only at the outset, but also at every stage of the disease. 

The first edition of this work was prepared with these ideas of 
completeness in view, and its early exhaustion is gratifying as an 
evidence that practitioners and teachers recognize the vital impor- 
tance of complete diagnosis, and have given their approval to an 
earnest effort to present a knowledge of it in available form. 

This opportunity for revision has been conscientiously utilized, 
and the new edition will be found to embody the latest approved 
advances and the newly established facts and methods in this most 



Vlll 



PREFACE TO SECOND EDITION. 



active and ^practical branch of medicine. The series of illustrations, 
which was already unusually large for a work of this character, has 
been enriched with many new engravings and colored plates. The 
author can claim to have been a most critical student of his own 
book, and likewise to have profited by the criticisms of other teachers 
and practitioners. 

Although there is no " royal road " to diagnosis, either through 
compends or more or less elaborate catalogues of diseases which aid 
the memory at the expense of comprehension and judgment, a 
serious study of the subject is repaid in the acquisition of a most 
valuable power. Modern research has placed this fundamental 
branch upon the plane of an exact science, and has correspondingly 
elevated the whole superstructure of medicine. Instruments and 
methods of precision, physical, chemical, microscopical, and bio- 
logical, are now so readily at the command of every practitioner 
that he is legally as well as morally bound to exhibit in his diag- 
nosis and treatment a degree of certainty far greater than could 
formerly have been exacted. 

In conclusion, it has been the primary purpose of this book to 
deal with the whole subject of diagnosis in its present state of 
development in clear language and with abundant illustration, to 
afford the practitioner a consultant upon which he might rely, and 
to present the facts and principles in such a manner as to give 
the undergraduate and postgraduate student a rational grasp and 
practical working knowledge of this fundamental science and art. 

The author takes this opportunity of acknowledging his renewed 
indebtedness to his friend, Dr. H. B. Allyn, for valuable assistance 
while the work was going through the press; to Dr. J. Allison 
Scott for the care and patience he took in supervising the production 
of most of the drawings and for suggestions in the chapter on Dis- 
of the Kidney; to Dr. Joseph Sailer, Dr. J. Dutton Steele, 
and Dr. James Ely Talley for timely suggestions and great aid in 
verifying references. To Mrs. Philip Putnam Chase the author is 
under obligations for the skill and patience required in the execu- 
ti .11 of many of the drawings. 

Street, Philadelphia, 
October, 1896. 



PREFACE TO FIRST EDITION. 



Modern methods of medical education demand that the student 
should be taught the expressions of morbid action, or, in other words, 
the phenomena of disease. He must be brought into contact with 
them in the hospital-ward and the outpatient-room, which are the 
medical laboratories where all the data are collected, analyzed, and 
used in discriminating the various disorders. 

The object of this volume is to aid the student in the pursuit 
of such laboratory-studies, and at the same time to furnish the prac- 
titioner with a reliable practical guide to diagnosis for use in his 
daily work. It has been thought best to combine in these pages 
the study of the objective phenomena or .signs of disease, the subjec- 
tive phenomena or symptoms, and the methods employed for their 
determination. Special attention has been paid to research for objec- 
tive phenomena appearing in physical, chemical, and biological changes 
in the tissues and secretions. The necessity for elaborate descriptions 
or extended lists of minutiae as guides to differentiation is being rap- 
idly displaced by the use of instruments of precision. Formerly, 
for instance, extensive tables were displayed to indicate the differen- 
tial diagnostic features of anaemia and chlorosis ; now a few moments' 
examination of the blood decides the nature of the affection, and 
whether iron or arsenic is to be given for its cure. 

The following pages bear evidence that the author does not under- 
value the direct and collateral data obtained by inquiry. Without 
them an examination carefully conducted according to all other 
methods may go for naught in the distinction of disease. 

The association of morbid processes with their phenomena is a prac- 
tice of the utmost importance to students, and a chapter has there- 
fore been inserted upon the Symptomatology of Morbid Processes. 
Bacteriological Diagnosis has become an established method by which 



x PREFACE TO FIRST EDITION. 

various disorders are recognized, and it is essential that the procedures 
in this new means of research should be fully outlined. The chapter 
on this subject is included not merely as a guide and reference for 
the trained student, but it is hoped that it will also emphasize the 
possibilities of bacteriological studies, and inspire those who are them- 
selves without facilities for prosecuting laboratory-work to have exam- 
inations made for diagnostic purposes by experts with laboratories at 
their command. 

My best thanks are due to my associate in private and hospital 
work and teaching, Dr. H. B. Allyn, for assistance without which 
this book could not have been written ; to Dr. H. Toulmin for aid in 
the collaboration of the sections devoted to the examination of Sputum 
and Feces ; to Dr. Charles Burr, of the Infirmary for Nervous Dis- 
eases, for the articles on Cerebral and Spinal Localization and on 
Electrical Diagnosis ; and to Drs. Joseph Sailer, W. H. Fenn, and 
J. E. Talley, for valuable assistance. 

Fortieth and Locust Streets, Philadelphia, 
February, 1894. 



CONTENTS 



PART I. 
GENERAL DIAGNOSIS. 

CHAPTER I. 

General Observations. 

PAGES 

The data upon which a diagnosis is based : The data obtained by inquiry. 
The data obtained by observation. Object of diagnosis — Requirements on 
the part of the student — Methods of diagnosis : Direct. Indirect (by exclu- 
sion). Differential — Diagnosis sometimes impossible. Avoid haste — 
Diagnosis should not be limited — Modern diagnosis — Case-record — Scope 
of the present volume ........... 17-23 

CHAPTER II. 

The Data Obtained by Inquiry. 

The Social History: Age, sex, occupation, habits, residence (past and 
present', family relations, exposure to contagion. The Family History: 
Parents, grandparents, brothers and sisters of each — brothers and sisters of 
patient — wife and children. The History of Previous Diseases. The History 
of the Present Disease : Duration. Mode of onset. Evolution of the disease 24-31 

CHAPTER III. 

The Data Obtained by Inquiry — {Continued). 

The Present Condition : The subjective symptoms — Mode of determina- 
tion — Their fallacy —Their value. Feigned disease. Local Subjective Symp- 
toms — General Subjective Symptoms ........ 32-35 

CHAPTER IV. 

The Data Obtained by Inquiry and by Observation — (Continued). 

Pain 36-58 

CHAPTER V. 

The Data Obtained by Observation. 

The objective symptoms correspond to phenomena in nature. Method of 
procedure; method of the observer. Inspection, palpation, percussion. The 
instruments required 59-63 



xii CONTENTS. 

CHAPTER VI. 

The Data Obtained by Observation — {Continued). 

PAGES 

The first sight impressions. General abnormal vital conditions. Fits or 
Seizures. Coma. Collapse. Shock. 1. The personal appearance. 2. The 
apparent age. 3. The temperament and constitution. 4. The attitude and 
gait. 5. The general for m and nutrition. The size — enlargement, diminution. 
The weight 64-79 

CHAPTER VII. 

The Data Obtained by Observation — (Continued). 

The face — the facial expression. The head. Mumps— facial hemiatrophy. 
Hydrocephalus. The hair. The lips. The neck— the thyroid gland — exoph- 
thalmic goitre — the bloodvessels of the neck . . . . ... 80-90 

CHAPTER VIII. 

The Data Obtained by Observation — (Continued). 
The Eye and Ear 91-109 

CHAPTER IX. 

The Data Obtained by Observation — (Continued). 

The extremities — hands. The shape — temperament — occupation — "claw- 
hands" — u seal-fin hands" — rheumatoid arthritis — nervous affections — 
"spade " hands— large bones of acromegalia — osteo-arthropathy — wrist-drop. 
The movements — spasm — tremor. The skin — color — moisture. Fingers. 
Heberden's nodosities — contraction of fascia — Dupuytren's contraction — de- 
viation in shape The nails. Trophoneuroses — cold hands and feet. Ray- 
naud's disease -erythromelalgia 110-118 

CHAPTER X. 

The Data Obtained by Observation — (Continued). 

The skin. The color — redness — pallor — jaundice — cyanosis — the bronzed 
skin — Addison's disease — hemochromatosis — chloasma — tinea versicolor — 
vagabond's disease — argyria — freckles. The nutrition. Moisture and dry- 
ness— hyperidrosis — anhidrosis. Scars. Hemorrhages — mode of recogni- 
nition — cause — significance. Eruptions — their clinical significance — nature 
of the lesion — distribution — associate morbid phenomena — general symp- 
toms. Table of skin diseases — erythema nodosum — urticaria — medicinal 
rashes — erythema of infectious diseases — roseola — milaria or sudamina. 
General diagnosis ........... 119-147 

CHAPTER XI. 

The Data Obtained by Observation— (Continued). 

The subcutaneous connective tissue. (Edema — causes — mode of recognition — 
situation— feet, face, arms, and head — oedema of trichinosis— angioneurotic 
oedema. Myxoedema. Connective-tissue dystrophies. Scleroderma. Sar- 
comata — cysticercus cellulosae — brawny induration. Subcutaneous nodules. 
The lymphatic glands. Enlargements — local — general. Adenitis. Hodgkin's 
disease. Tuberculosis and leukaemia 148-162 



CONTENTS. xiii 

CHAPTER XII. 

The Data Obtained by Observation— {Continued). 

PAGES 

The muscles — idiopathic muscular atrophy — pseudo-hypertrophy— Thorn- 
sen's disease — paramyoclonus multiplex. Myositis — myalgia — muscular 
rheumatism ............. 163-168 

CHAPTER XIII. 

The Data Obtained by Observation — [Continued). 

The bones — general examination. Enlargement — acromegaly— osteitis de- 
formans — pulmonary osteo- arthropathy — diminution — rhachitis — osteomalacia. 
Local examination — position and shape — nodes — inflammation — osteomye- 
litis 169-190 

CHAPTER XIV. 
The Data Obtained by Observation — (Continued). 
Chills ; fever ; subnormal temperature ........ 190-208 

CHAPTER XV. 

The Data Obtained by Observation — (Continued'. 
Fever. The Intoxications 209-216 

CHAPTER XVI. 

The Data Obtained by Observation — (Continued). 

Fever. The Infections. Causal relation of bacteria to disease, Koch's 
laws, value in diagnosis. Bacteria : Saprophytes, parasites, pathogenic, non- 
pathogenic, aerobic, anaerobic, facultative anaerobic. Morphology: Micro- 
cocci, bacilli, spirilla — Micrococci. Morphology : Form and size. Repro- 
duction, fission ; grouping. Biological characters : Non-motile. Pigment 
production. Liquefaction of gelatin. Production of acids. Toxic ptomaines 
and toxalbumins — Bacilli. Morphology : Form and size. Reproduction, 
fission, spores ; grouping. Biological characters: Motility. Pigment pro- 
duction. Liquefaction of gelatin. Production of acids. Putrefaction, fer- 
mentation. Spirilla. Morphology : Form and size. Reproduction, fission ; 
grouping. Biological characters. Motility. Pigment-production. Lique- 
faction of gelatin. Production of acids and fermentation wanting . . 217-222 

CHAPTER XVII. 
The Data Obtained by Observation — (Continued). 

Fever. The Infections. Data obtained by inquiry — By observation. 
Local infection — General infection. Pyaemia ; septicemia. Terminal infec- 
tions. Fever in carcinoma. Afebrile infections. Infections of certain bac- 
teriology ; of uncertain bacteriology. Bacteriological diagnosis. Method of 
research : Microscopical examination, cultivation, inoculation. Essentials 
in technique— Method of research: Blood, discharges, exudations; mode of 
collection. Apparatus. Preparation of apparatus. Sterilization. Micro- 



XIV 



CONTENTS. 



scopical examination : Technique, cover-glass preparations. Methods of 
staining ; spores. "Hanging drop'' — cultivation of micro-organisms. Cul- 
ture-media. Tube- and plate-cultures. Smear- and stab-cultures — Inocu- 
lation of animals — Special bacteriological diagnosis 



223-245 



CHAPTER XVIII. 

The Data Obtained by Observation — (Continued). 

Fever. The infectious diseases. Infections not recognized by bacterio- 
logical or blood examination . . . . . . . . '. 246-273 



CHAPTER XIX. 

The Data Obtained by Observation — (Continued). 
Fever. The infectious diseases. Infections recognized by examination 



of the blood 



274-308 



CHAPTER XX. 

The Data Obtained by Observation — (Continued). 

Fever. The infectious diseases. Infections recognized by the examina- 
tion of excretions and secretions or by the products of the infectious inflam- 
mations ............. 



309-356 



CHAPTER XXI. 

The Data Obtained by Observation — (Continued). 

Exploratory puncture or aspiration for diagnosis: Instruments. Preparation 
of instruments. Preparation of skin. Point of puncture. — Exudations (Pus- 
Sero-pus. Gangrenous debris. Blood. Serum. Chyle) : Pus. Blood- 
corpuscles. Bacteria. Protozoa. Vermes. Crystals — Chemical examina- 
tion: Sero-purulent exudations. Putrid exudations. Hemorrhagic exu- 
dations. Serous exudations. Chylous exudations. Pleural effusions. Trans- 
udations. — The contents of cysts : Hydatid, ovarian, renal, pancreatic 



357-368 



CHAPTER XXII. 

The Blood 



369-399 



CHAPTER XXIII. 

The Morbid Processes and their Symptomatology. 

Knowledge of symptoms of morbid processes essential ; they control con- 
clusions drawn from data. — Morbid processes are few. I. Alterations in 
blood and circulation. Anaemia and plethora — Hyperemia, active and 
passive — (Edema and dropsy — Thrombosis and embolism — Hemorrhage — 
Blood-pressure. II. Disturbances of nutrition: Inflammation — Gangrene 
and necrosis — Fever— Atrophy and hypertrophy. Degenerations: Albu- 
minous — Fatty — Colloid— Mucous — Pigmentary — Calcareous — Amyloid — 
Fibroid. III. Anomalies of growth : Tumors— Cysts — Cancer . 



400-416 



CONTENTS. xv 

PART II. 

SPECIAL DIAGNOSIS. 

CHAPTER I. 

PAGES 

The Nose and Larynx .... 417-449 

CHAPTER II. 

Diseases of the Lungs and Pleurae . . . 450-579 

CHAPTER III. 

Diseases of the Heart, the Bloodvessels, and the Mediastinum 580-685 

CHAPTER IV. 

Diseases of the Mouth, Fauces, Pharynx, and (Esophagus 686-724 

CHAPTER V. 

Diseases of the Stomach, Intestines, and Peritoneum . 725-853 

CHAPTER VI. 

Diseases of the Liver, Spleen, and Pancreas . 854-899 

CHAPTER VII. 

Diseases of the Kidneys . . . . 900-968 

CHAPTER VIII. 

Diseases of the Nervous System . . . 969-1062 



ERRATA 



Page 203, third line from top, omit "disease" after "malingering." 
Page 230, twelfth line from bottom, for "moist," read "most." 

Page 268, seventh line from bottom, for "in a week," read "in about three weeks." 
Page 272, fourth line from bottom, insert "actinomycosis" after "glanders." 
Page 277, fifth line, omit the "comma" after "malignant." 

Page 282, fourth paragraph, second line, for "four hours," read "forty-eight hours.' 
Page 284, third line from top, for "roseate" read "rosette." 
Page 289, third paragraph, fifth line, insert "combined" after "ulceration." 
Page 299, third line from bottom, for " forms are decreased," read "forms are rela- 
tively increased." 

Page 305, fourth paragraph, fifth line, for "1 to 5," read "1 to 50." 
Page 359, thirteenth line from bottom, for "intercellularis," read " intracellulars. " 
Page 369, sixth line from bottom, for "identity," read "entity." 
Page 373, fifteenth line from bottom, for "value," read "volume." 
Page 386, third paragraph, first line, for "acidity of blood," read "alkalinity of 
blood" in both places. 

Page 489, fifth line from top, insert "tissue" after "pulmonary." 

Page 491, thirteenth line from top, for "implies," read "applies." 

Page 496, fifth line from top, for " tympanite" read "tympanitic." 

Page 611, second paragraph, third line, for "distended" read "distending." 

Page 821, fourth line from top, for "tubules" read "intestines." 



MEDICAL DIAGNOSIS. 



PART I. 

GENERAL DIAGNOSIS. 

CHAPTER I. 

GENERAL OBSERVATIONS. 

The data upon which a diagnosis is based : The data obtained by inquiry. The data 
obtained by observation. Object of diagnosis — Requisites on the part of the 
student — Methods of diagnosis : Direct. Indirect (by exclusion). Differential 
— Diagnosis sometimes impossible. Avoid haste — Diagnosis should not be lim- 
ited — Modern diagnosis — Case records — Scope of the present volume. 

The sufferings of one avIio comes under the care of a physician are 
indicated by symptoms of which the patient himself is cognizant, and 
for which usually he applies for relief ; or by alterations of the physical 
or chemical structure of the whole or a part of the body, or of the 
functional activity of organs — alterations which, although not apparent 
to him, are evident to the observer, the physician. The symptoms of 
which the patient complains, and of which he alone has knowledge, 
are known as the subjective symptoms of disease. The symptoms which 
the physician observes, some of which, as the changes of the exterior, 
may be apparent to the patient, are known as the objective symjrfoms of 
disease. 

The subjective symptoms of disease, as well as such objective symp- 
toms as the patient is aware of, have a history. It may be the brief 
one of sudden onset, or a long one of rise and fall, of ebb and flow, of 
the mingling of complex phenomena from time to time. The story of 
the evolution of the disease is written as the history of the present 



The present disease may be due to previous attacks of disease, or be 
modified by the occurrence of previous disease. We may be consulted 
for the effects of one link in a chain of morbid disorders which began 
in infancy or early adult life. We should learn, therefore, of the occur- 
rence of previous disease. Certain types of constitution and some few 
diseases are transmitted by parents to offspring ; we should, therefore, 
inquire into the family history. A further insight into the nature of 
the suffering may be obtained by a knowledge of the age, sex, habits, 

2 



18 GENERAL DIAGNOSIS. 

occupation, environment, etc. — in short, by a knowledge of the social 
history — for, if the cause of the disease under consideration is deter- 
mined, a distinction from other affections with allied phenomena can 
frequently be made. 

The subjective symptoms, the history of the present disease, the previous 
history, the family history, and the social history are learned by inquiry 
of the patient or the friends of the patient by methods and within 
limitations hereafter to be described. It is proper that they should be 
ascertained, if practicable, before the objective symptoms are studied. 

After the story of the patient is ascertained in full, the objective symp- 
toms are sought for. Examination of the patient by the use of the 
senses of sight, of touch, of hearing, with the instruments of precision 
to aid them — the physical examination — and by chemical and bacteri- 
ological methods, reveals the presence or absence of the latter class of 
symptoms. 

The phenomena of disease are ascertained, therefore, by inquiry 
and by observation. The facts or data thus collected and the dis- 
criminate interpretation of them constitute diagnosis. 

Object of Diagnosis. The object of diagnosis is to determine the 
condition of the living patient who may be suffering from disease. It 
implies not only that the phenomena of disease are detected, but also 
that the effects of the disease on the organism are determined, and 
that the morbid process which is the cause of the phenomena is ascer- 
tained. Even this is too restricted an idea of diagnosis. It should 
include also the recognition of the cause of the morbid process. The 
latter is known as the etiological diagnosis. In addition to naming the 
disease and its cause we should include in the diagnosis a determina- 
tion of the stage of the disease and the recognition of its complications. 
Moreover, diagnosis implies such knowledge of the patient's condition 
as to enable an estimation of the dangers liable to arise and of the 
outcome of the disease — the prognosis. 

Diagnosis is not made in order to give the disease a name alone but 
to treat it, and as it is not disease that we treat but a patient with an 
ailment, full knowledge of the patient and of his environment, his 
mode of life, habits, occupation, etc., must be obtained by inquiry. 

The practical result of diagnosis is the ability to remove or prevent 
the occurrence of the morbid processes, or to mitigate their effects by 
rational therapeutics. 

Requisites on the Part of the Student. As data are to be col- 
lected by inquiry and by observation, it is obvious that he who would 
inquire and observe intelligently and successfully must be possessed of 
knowledge and qualifications of a high order. The phenomena of 
health must be familiar to him. He must have a full knowledge of 
physiology, to recognize the aberrations of function, and of pathology, to 
understand the production of symptoms by disease. He must know 
the organic results of pathological processes — morbid anatomy. He 
must have learned, by reading and experience, the significance of symp- 
toms, or of groups of symptoms, and their relation to morbid processes. 



GENERAL OBSERVATIONS. 19 

He must have a knowledge of the evolution of disease and the phe- 
nomena of each period in its development, to secure an accurate account 
of the disease under consideration. He must know the influence of 
morbid processes on the body and their effect in the production of sub- 
sequent disease, in order to ascertain correctly the various diseases of 
the patient and infer rightly their relation to the phenomena under 
consideration. The significance of the family history can be appreciated 
and correctly applied only by a knowledge of the diseases which are 
inherited or which arise in certain physical types of individuals, which 
type is inherited. The social history is not worth securing unless the 
inquirer knows the influence of age and sex, of race, of occupation, of 
habits, of residence, of degree of labor, in the development of disease, 
or the influence of the environment on the individual — the action and 
reaction of external forces on forces within. 

To ascertain the objective symptoms, he who would observe properly 
must knoAV anatomy, to recognize the seat of the disease, and physiology, 
to discern the departures from health. He must be trained at the bed- 
side in the use of the senses, and know how to discriminate and inter- 
pret phenomena observed by them. He must know how to use instru- 
ments of precision, as the microscope, and must learn its revelations. 
The laws of chemistry and the methods of chemical examination must 
be familiar to him. Bacteriology and the data obtained from its 
methods must be appreciated fully. 

It is thus seen that the inquirer must have knowledge gained by 
reading and knowledge gained by observation at the bedside and in the 
post-mortem room. He acquires thus, on the one hand, the recorded 
experience of others, and learns that certain symptoms under certain 
circumstances indicate a definite malady. On the other hand, he learns 
that certain symptoms are associated with definite lesions. 

Methods of Diagnosis. But we must not only secure facts, we 
must also be able to utilize them for analysis and induction — the result 
of which is the formation of the diagnosis. The diagnosis is obtained 
by three methods — the direct, the indirect, and the differential. By the 
direct method the data collected are sufficient to warrant a positive con- 
clusion. An indirect diagnosis is made by exclusion. A symptom 
group may represent several diseases. Each affection is passed in 
review and excluded until one is found to correspond more closely to 
the data of the case under consideration. It is not one, because of the 
absence of certain symptoms ; it is not another, because of the presence 
of certain essentially different symptoms. A negative is thereby 
proven. By the differential method the diagnosis of one of a few pos- 
sible diseases must be made, the data for and against which are passed 
in review. The direct method is scientific, rational, and the most prac- 
tical. It is a process of pure inductive reasoning. 

Diagnosis Sometimes Impossible. Notwithstanding our efforts 
to collect data by inquiry and by observation, we are often unable to 
make a diagnosis. This arises when premises are wanting for the pro- 
cess of induction. The subjective symptoms may not tally with the 



20 GENERAL DIAGNOSIS. 

known processes of disease, or the narrator of the history of the present 
disease may omit important evidence from lack of memory or knowl- 
edge, from design, or for other reasons. The objective phenomena may 
be developed in an ill-defined way, or they may be obscure, as the state 
of the abdominal contents in a person who is obese ; or they may point 
to one or more processes the subjective symptoms of which are not 
present. At the time of observation the disease may not have devel- 
oped fully, may not have " spelled itself out." Under these circum- 
stances a provisional diagnosis must be made or conclusions held in 
abeyance. If we are considering a contagious disease, for sanitary 
reasons, the infectious disease should be given the benefit of the doubt. 
If, on the other hand, the disease requires prompt remedial action, the 
symptoms must be taken as the indication for therapy. 

Avoid Haste. If prompt action is not required, too great haste 
should be avoided. It is not necessary to make a diagnosis at once, 
and it is not a confession of ignorance if time is asked before an opinion 
is given. Repeated observation and reflection should be employed 
before a conclusion is arrived at. This particularly applies to the class 
of cases which represent a condition the resultant of improper environ- 
ment, for the proper detection of which social data, knowledge of tem- 
perament, etc., must be acquired. Then, again, it may be necessary to 
observe the patient under changed circumstances, or study the effects 
of diet on renal secretion, or on the function of other organs. Haste 
leads to faulty diagnosis, and therefore to misdirected therapeusis. 

Diagnosis Should Not be Limited. It is not sufficient to give a 
name to a group of symptoms and be satisfied that the diagnosis is 
made. Every method must be used to collect data. The exact physi- 
cal condition of the patient must be ascertained and the functional 
powers of all the organs correctly determined. We thus learn if the 
more evident disease is the single expression of a morbid process, or if 
it is the surface storm, the currents of which are underneath. A pleu- 
risy or pneumonia may be the outcome of or complicate a latent 
nephritis. A peritonitis may be the sequela of an appendicitis or pyo- 
salpinx. Or diseases in two or more organs, due to the same process, 
may exist at the same time, as suppurative pleuritis and pericarditis. 
It would not be sufficient to recognize one of the affections alone. 

For purposes of treatment it is not sufficient to recognize a neuralgia 
or a spasm. The state of the patient on account of which the neuralgia 
developed must be ascertained. Attention must be called to the im- 
portance of not being lulled into a false security by the belief that the 
diagnosis of the first day is sufficient. Complications may arise or the 
morbid process invade new territory. Thus, in the course of pneu- 
monia, in a few days a meningitis may arise or an ulcerative endocar- 
ditis ensue. 

Modern Diagnosis.. Anyone who takes the trouble to recall the 
methods of diagnosis that were in use twenty years ago will be struck 
by the wonderful expansion of the means now at hand to unravel the 
mysteries of disease. Then a few instruments of precision and a few 



GENERAL OBSERVATIONS. 21 

chemical reagents were required. The microscope was employed to 
examine only a few of the excretions and the blood. Now the instru- 
ments of precision are multiplied and the scope of their explorations is 
increased. 1 Chemistry, among other things, helps to fathom the mys- 
teries of gastric disease. The microscope has extended its domain, 
and, with the new methods of staining fluids and tissues, has become 
the key that unlocks many of Nature's secrets. The new science of 
bacteriology has come to our aid, and now instead of waiting to estab- 
lish a diagnosis until an epidemic counts its victims by hundreds it is 
obtained at once. 

Certainty in diagnosis, for these reasons, has made a decided advance. 
The number of diseases which can be positively diagnosticated has in- 
creased. Methods of investigation and new instruments of precision 
are increasing daily. May we not hope that in the future the horizon 
of absolute knowledge will be extended far beyond its present limits ? 
New instruments and new methods will surely avail. 

The use of the large number of instruments that are essential, and 
the chemical and bacteriological examinations that are made, require 
a great deal of time. Often the diagnosis is a question of hours or 
even of days. The patient profits thereby. The tax on the physician 
is far greater than it was a few years ago. The bedside labor is great, 
and, in addition, he must haye a laboratory at his command for micro- 
scopical, chemical, and bacteriological work. The outcome is that the 
scientific physician must have a clientele limited in number, or else have 
one or more assistants to aid him in his investigations. Without doubt 
the latter will soon occur. Not as in days of old will we find in the 
practitioner's office the apprentice, compounding drugs and rolling 
bandages, assisting in the operations of bleeding and dressing ulcers, 
but the highly trained, scientific assistant, who by labors in the labora- 
tory and at the bedside is competent to collect data suitable for scien- 
tific methods of reasoning. 

Case Records. Records of cases should be kept for obvious reasons. 
The habit compels a general survey of the case, and tends to prevent 
oversight in the examination. It naturally aids in the training of the 
powers of observation. It teaches precision in the narration of cases. 
The memory is aided by repetition and by lack of haste in ascertaining 
phenomena. The data are on record for more mature reflection, and to 
aid in the study of the literature of similar cases. The record is of 
value in case the patient returns for advice after a lapse of time. It 
may be of medico-legal value. The mental effect on the patient is 
good, for the taking of notes requires time and accurate studied obser- 
vation. In case it is desired to study a large number of cases, records 
are scientific data. The records may be kept on loose sheets and filed 
for future use. When a sufficient number are secured they may be 
classified and bound in volumes devoted to the various diseases, or 
they may be noted in a blank-book. At the end of the year the book 

1 As a most simple illustration, witness the knee-jerk and reflexes, learned by per- 
cussion, an old method, in extended use. 



22 GENERAL DIAGNOSIS. 

is indexed according to the diseases and the names of the patients. A 
better method is by a system of cards. The cardboard should be six 
by eight inches. One card is devoted to each case, although more can 
be used. They are arranged and catalogued according to the library 
system of card catalogues. 

Method of Record. A systematic plan must be pursued in noting 
the cases. It need not correspond to the lines of inquiry in the exami- 
nation of the patient, which are modified by the circumstances of the case. 

The following outline explains itself. The various data should be 
recorded in sequence, and in such manner that the facts of each line of 
investigation can be readilv culled for review and analvsis. (See Chap- 
ters II. and III.). 

KECOKD OF CASE NO. — . 
Diagnosis. Result. 

Name and residence, place of birth, and former residence. 

I. Social history : Age, sex, race, married or single, children, the number and 

health ; miscarriages. 
Occupation : Present and previous home surroundings, sanitary conditions, etc. 
Habits: Tobacco, alcohol, tea, narcotics; sexual habits; regularity of meals, 

character of food, and method of eating; number of hours of sleep, degree of 

fatigue ; brain-use, exercise. 

II. Family history : Hereditary tendency ; health of parents, brothers, sisters, 

etc. Cause of death and age at which it occurred. 

III. Htstory of previous diseases : Character of convalescence from ; syphilis 
and gonorrhoea ; injuries. 

IV. History of the present disease : Date, mode of onset, and probable exciting 
cause of present trouble ; evolution of the disease to date of examination. 

V. The present condition : 

A. Inquiry : The subjective symptoms. 

B. Observation : The objective symptoms. 

External appearance, development, color, figure, height and weight, attitude, 
expression of face. 

Temperature, perspiration, eruption, swelling. Condition of limbs and joints. 

Examination of the digestive apparatus : Mouth, tongue, gums, and pharynx ; 
abdominal organs ; contents of stomach, faeces. 

Examination of respiratory apparatus: Nose, mouth, and larynx. The lungs : inspec- 
tion, palpation, percussion, auscultation, mensuration. Cough and expectoration. 

Examination of circulatory apparatus: Inspection and palpation of cardiac area 
percussion, auscultation of heart; similar examination of arteries and veins; 
the pulse ; examination of the blood. 

Examination of the urinary apparatus : Kidneys, ureters, and bladder ; examina- 
tion of urine. 

Examination of the nervous system : Intelligence, subjective nervous phenomena, 
sleep, gait, station, reflexes, paralysis, tremor, pain, convulsions, headaches, 
disturbances of sensation, disturbance of speech. The organs of special sense. 

Examination of fluids obtained by puncture. 

Bacteriological examination of blood, sputum, secretions, exudations, etc. 

Diagnosis. 

Prognosis. 

Treatment. 



GENERAL OBSERVATIONS. 23 

How to Use the Book for Diagnosis. We must anticipate a 
little. The student can by ready reference make practical use of the 
work as the hand-book is used in the laboratory. It is supposed that 
the case has been thoroughly investigated, according to the directions 
indicated in the book, and the data arranged in accordance with the 
case record. An analysis of the data is then made. The value of 
that obtained by inquiry and that obtained by observation is carefully 
considered. The diagnostic significance of the respective data may be 
found by consulting the index or by a review of the chapters devoted 
to the special subject. • An estimate of the value of the data obtained 
by inquiry, including the subjective symptoms of disease, will be found 
in the sections devoted to general diagnosis if the data are general 
(Chapters II. to XXII. inclusive). If the data obtained by inquiry 
refer to special organs they will be estimated in the sections on special 
diagnosis that treat of the manifestations of disease in the respective 
organs. In the same manner data obtained by observation that are of 
a general character are considered in the sections on general diagnosis. 
Data pointing to disease of special organs are considered in the chapters 
treating of the respective organs. 

It must be understood by the student that by general data we mean 
such as may be expressive of the disease of various internal organs. 
Thus, the student of internal medicine examines the eye not with the 
view of finding any special disease of that organ, but to note any 
changes, physiological or anatomical, which may have resulted from 
primary disease elsewhere. Diseases of the nervous system, of the 
blood, of the heart, or of the kidneys may be expressed in eye altera- 
tion of some kind. Similarly, the skin, the bones, and joints, as well 
as other structures, are studied. Many internal diseases will have their 
outward or physical expression in general anatomic change or in the 
change of one set of tissues. When this is the case the disease will 
be discussed when considering its most manifest external expression, as 
myxoedema under " enlargements " of the body and acromegaly under 
" bones and joints." The book is arranged, therefore, for diagnostic 
convenience and not for pathological classification. 



CHAPTER II. 

THE DATA OBTAINED BY INQUIEY. 

The Social History : Age, sex, occupation, habits, residence (past and present), family 
relations, exposure to contagion. The Family History : Parents, grandparents, 
brothers and sisters of each — brothers and sisters of patient — wife and children. 
The History of Previous Diseases. The History of the Present Disease : Duration. 
Mode of onset. Evolution of the disease. 

Mode of Procedure. First the subjective symptoms of the disease 
are elicited, so that, if necessary, measures may be directed for the 
patient's relief at once, and that we may have the advantage of obser- 
vation of the patient's intelligence, expression, etc., and at the same 
time ascertain the direction further inquiry should take, in order 
that embarrassment may pass oft' and composure ensue before an 
objective examination is made. It seems preferable, however, to begin 
the record with the social history of the case, for a scientific and orderly 
procession in the data acquired, and then proceed to record the facts of 
family history, previous history, and history of present disease. Cer- 
tainly it is immaterial how they are considered in the following discus- 
sion, and for convenience, therefore, the above order will be followed. 
It is to be remembered that the patient's complaints and the objective 
phenomena — or, if the patient is unconscious or otherwise unable to 
speak intelligently, the latter alone — are the central threads around 
which the diagnosis is woven. 

The Social History. 

The aid to diagnosis obtained from inquiry into the social history 
cannot be considered exhaustively. Works on hygiene must be con- 
sulted. General ideas will be given ; reference to the influence of 
various factors will be found under the individual diseases. That 
such data are of value is illustrated in various forms of colic. For 
instance, knowledge that the patient labored in lead ivill often simplify 
the diagnosis of the nature of this symptom. 

The Age. The age is learned, for each period in the evolution and 
involution of life has its peculiar physiological processes susceptible to 
variations by external influences. 

A large group of affections arise in the first period of infancy, from 
inheritance or congenital malformations, from accidents incident to 
parturition, and from improper management of the cord. In a later 
period, in acquiring adaptability to environment, by the feebly resist- 
ing organism, disturbances of digestion from poorly prepared or improper 
food arise ; pulmonary disorders from improper clothing, ventilation, 
etc., occur. The developing nervous system has more acute suscepti- 



THE DATA OBTAINED BY INQUIRY. 25 

bilities, and hence a long array of reflex symptoms or diseases is ob- 
served at this period. Another group of diseases, the exanthemata, and 
almost all contagious diseases, are more prevalent in childhood, because 
they arise out of exposure to a specific cause which usually occurs 
before the child attains many years. The anatomical arrangement of 
the larynx, disproportionately small, makes the diseases of that organ 
most frequent in childhood, and a serious factor in mortality. 

At puberty we see the perversions (from earlier years) liable to arise 
as adolescence advances. Ansemia and chlorosis are prone to develop 
at this period. In the middle period the diseases that arise from occu- 
pation, from exposure to external agencies, from habits, are seen. 
Moreover, processes beginning in adolescence are reaching their acme, 
and find expression in later life, as the cysts of hydatid disease, or renal 
calculi, or manifestations of gout. In later life degenerations of the 
vascular and cerebro-spinal systems occur ; affections due to fibrosis, 
a resultant of wear and tear, as atheroma ; cancer ; calculous disease, 
and other diseases prevail. 

The Sex. The prevalence of various diseases in the sexes in undue 
proportion arises because of difference in the anatomical structure and 
physiological offices of the two, and because of the difference in expo- 
sure to varying causal agencies. Diseases more common to the male 
sex occur on account of occupation, from exposure, from over-activity 
of mind and body, and, finally, from the formation of bad habits. 
The diseases of the female sex that are more prevalent, apart from their 
own peculiar affections arising out of menstruation and childbearing, 
take place because of the more or less sedentary nature of their lives, 
and hence, among other things, the opportunities for introspection. 
Hysteria, neurasthenia, and nerve disorders abound with them. Males 
are more subject to epilepsy, gout, diabetes, locomotor ataxy, and vesi- 
cal disease. Females are more subject to exophthalmic goitre, rheu- 
matoid arthritis, chorea, and the above-mentioned nervous disorders. 

Occupation. This must be ascertained in the inquiry, for each 
occupation demands effort in one particular direction, or compels expo- 
sure to deleterious influences. Writer's cramp, eye-strain, and a series 
of disorders thus arise. Knowledge of exposure to particular irritants, 
coal or fine particles of metal or stone, gases, chemicals, effluvia of all 
kinds, and to diseases contracted from animals, is valuable in diagnosis. 

The manner and degree of employment of the mind must be inquired 
into. 

It is not to be forgotten that the occupation at different periods of 
life must be found out, the age at which life's battle began, and the 
circumstances that surrounded the early career. The deleterious influ- 
ence of a former occupation may be observed after the patient is in an 
entirely different sphere of labor. 

Habits. Habits as to clothing (catarrhal affections and rheumatism), 
as to hours of rest and sleep (neurasthenia), as to character of food, 
time, regularity, and manner of eating (the indigestions, gout), as to 



26 GENERAL DIAGNOSIS. 

exercise, and as to the use of alcoholic stimulants (cirrhosis of the liver, 
neuritis, brain affections), of tobacco (amblyopia, cardiac palpitation), 
of tea or coffee, of narcotics, must be inquired into. Methods of work, 
methods of recreation, domestic joys or sorrows, must be ascertained. 
A knowledge of the habits, of the life (of the inner life, indeed) of 
the individual, is essential to a rational diagnosis, and hence a true 
therapeusis. 

Place of Residence and Dwelling. A knowledge of the place of 
residence is of service. Town residence and country residence, a resi- 
dence in a damp locality, by the sea and in the mountains, in particular 
valleys, in different water-sheds, in tropical or frigid clime, each makes 
an impress on the constitution, even if actual disease is not created. 
Hence malarial regions, goitre districts, localities in which individuals 
have to an unusual degree vesical calculi, or in which special epidemic 
diseases abound, as yellow fever, cholera, or dysentery, must be inquired 
for. Knowledge of the places of residence at different periods of life 
and the duration of such is often important information. 

The situation and degree of comfort for habitation of the dwelling 
must be learned. The sanitary arrangements — drainage, ventilation, 
water-supply, heating — are to be scrutinized. 

Family Relations. Marriage and the number of children, with 
their degree of health, must be recorded. If a woman, the number of 
children born, the character of the labors, the number of miscarriages. 

Is there trouble in the marital relation ? Has there been sorrow, or 
sudden shock, or long nursing, or great care ? Are the financial cir- 
cumstances easy ? Has there been recent malfeasance ? How many 
invalid women arise out of such ashes ! 

Questions so personal can only be put after long acquaintance, or 
information obtained through judicious inquiry of friends. 

Frequently more delicate questions must be put, as to masturbation 
or excessive venery, but with great caution, and only when conditions 
demand it. In epileptiform convulsions, profound hysteria, neuras- 
thenia, the development of locomotor ataxy, or spinal paralysis, prompt, 
clear, manly questions as to these habits are to be put, not reference 
made to them in prudish or mawkish suggestion. 

Exposure to Contagion. If the suspected ailment partakes of the 
nature of a contagious disease, the probability of exposure to the disease 
must be looked into and the presence of epidemics ascertained. The 
period of incubation must be known in such cases. The prodromal 
symptoms must also be known. 

The Family History. 

This inquiry is instituted in order to determine the affections which 
may or may not be hereditary. We learn also the average duration 
of life in the family and the relation of the mortality to the physio- 
logical epochs in life. Data of the latter character are of value in esti- 



THE DATA OBTAINED BY INQUIRY. 27 

mating the possible duration of life for purposes of life insurance, and 
they also throw light on abnormal conditions ; thus to learn that most 
of the members of the family died of apoplexy at a comparatively early 
age, or of aneurism or of arterial degenerations, is to learn that vascular 
changes developed earlier than usual. To secure accurate data, the 
age and state of health of parents, brothers, and sisters, if living, are 
ascertained ; or, if dead, the cause of death and age at which it took 
place. Similar questions may be applied to several generations of the 
family and to collateral branches. 

Inherited Diseases. Concerning the question of direct inheritance 
of disease, but few are strictly so. Of these, nervous diseases are the 
most common, as progressive muscular atrophy, hereditary chorea, 
Thomsen's disease, Friedreich's ataxia, migraine, epilepsy, and forms 
of insanity. The writer has seen chronic Bright' s disease, or a state of 
the constitution that predisposes to it, occur in several generations 
without the usual exciting causes of that affection. Syphilis may be 
inherited. Haemophilia is the most striking affection that is trans- 
mitted by inheritance. Generally it is not the diseases themselves that 
are hereditary but types of tissue that predispose to disease, as in 
tuberculosis or cancer ; or conditions of the organism that favor imper- 
fect metabolism, as is seen in gout or rheumatism. 

The family physician, who comes in contact with one or more gener- 
ations, profits most by the knowledge of the family history. He learns 
the predisposition to various minor ailments — to headaches and attacks 
of indigestion, " bilious attacks," for instance ; he learns the power of 
resistance to disease in the family, or their capability to undertake 
large duties in life ; he learns their susceptibility to drugs and their 
tendency to take stimulants. Nerve force is the capital with which 
the battle of life is kept up. If it is at a minimum in groups of 
families, diseases or conditions of poor health due to its use — a use not 
excessive in others — arise. 

Contagious Diseases. In the inquiry it may be well to ascertain 
the probability of disease being transmitted from husband to wife, or 
the opposite. Syphilis and gonorrhoea and tuberculosis are examples. 
Not only may this probability apply to the transmission of disease from 
husband to wife, but to its transmission along lines of families. Then, 
too, we must inquire of mothers for the manifestations of syphilis in 
the children. 

Caution must be exercised in the pursuit of knowledge of this kind, 
as strained, or even ruptured, marital relations may result from injudi- 
cious intimations. 

Malignant Disease. Caution must be employed in order not to 
arouse family pride if evidence of " scrofula " is sought for, or to pro- 
voke undue alarm when inquiry into the family history of cancer is 
made. Disarm suspicion by inquiring for the symptoms of the disease 
in various organs in which it may occur, as jaundice, uterine hemor- 
rhage, etc., or ask about growths or tumors. Do not use the specific 
terms, consumption and cancer. 



28 GENERAL DIAGNOSIS. 

Obscure Terms. Moreover, care must be exercised to secure defi- 
nite data, not to over-estimate statements as to the cause of death being 
" dropsy," or " jaundice," or " cold," or " teething," or " change of 
life." Control questions must be put by inquiry into the character of 
the symptoms that attended the fatal illness, and by giving the affections 
the various popular names that are given them in different countries. 

Common Morbid Processes. The data of the family history are 
of no avail unless it is remembered that many fundamental affections 
have various modes of expression. Various diseases may be allied to 
the one suspected to exist in the patient, and be overlooked because of 
this difference of expression. One member of the family may die of 
heart disease, another of rheumatism, or some have had chorea, or 
cutaneous affections, or renal calculi ; such ailments are expressions of 
the same morbid process. Finlayson well puts them into groups and 
fittingly portrays them as follows : "In regard to scrofulous [tuber- 
culous] diseases, we ask for swollen glands or ' waxy kernels/ or running 
in the neck, diseases of the spine and other bones, bad joints, white 
swellings, or c incomes/ as they are termed in Scotland ; disease of the 
glands, of the bowels, water in the head, consumption of the lungs, or 
decline, or weakness of the chest, with spitting of blood, and so on. 

" Heart disease, rheumatism, chorea, psoriasis, and some other cuta- 
neous affections, and perhaps renal concretions and emphysematous 
bronchitis, appear to replace each other in different members of the 
same family. 

" The neurotic group includes the various forms of neuralgia, epi- 
lepsy, hypochondriasis, hysteria, and insanity ; apoplexy and hemiplegia 
may (perhaps doubtfully) be included in this group ; their hereditary 
character seems rather to be associated with vascular disorders. Gout, 
disease of the liver, contracted kidney, renal calculus and gravel, and 
angina pectoris form another allied group ; and these have also some 
affinity with the disorders connected with arterial degenerations. Syph- 
ilis, which, of course, has marked hereditary characters, assumes such 
a multitude of forms as to preclude enumeration ; but the tendency is 
for such syphilitic diseases to fail in the course of time from early death 
or sterility. Abortions, stillbirths, early deaths in infancy, associated 
with cutaneous eruptions on the buttocks and with snuffles, are im- 
portant in many family histories ; nervous deafness, opacities of the 
cornea, notched teeth, epilepsy, and imbecility are occasional manifes- 
tations of the same disorder in those children who survive." 

Conclusions. It is thus seen that in securing the family history 
data are acquired which may be (1) complete and of value in estimat- 
ing family tendencies or (2) vague and of doubtful value. The latter 
is due to lack of memory on the patient's part or to his ignorance of 
technical terms. The difficulties must be overcome by control ques- 
tions prompted by our knowledge of the nature of the disease and its 
frequency at different ages, by an inquiry for symptoms, and by inves- 
tigation into collateral and remote branches of the family. 



THE DA TA OB TAINED B Y INQ UIR Y. 29 

The fact that diseases skip a generation (atavism) must be remem- 
bered. A generation may be small or decimated by accidental disease, 
and hence the force of the family history be weakened. At times in a 
family sufficient time has not elapsed for predisposition to arise, as 
when we inquire into the illness of a child whose parents are in early 
adult life. Finally, all negative facts must be recorded. Such knowl- 
edge must act as a control element in estimating the value of the family 
history. 

The History of Previous Diseases. 

The remote effects of disease, and of its sequelae, as impressed on the 
organism, make it essential to inquire into the nature of the previous 
diseases of the patient whom we are studying. The date and character 
of the disease, the duration, the degree of severity, and the completeness 
of convalescence must be determined. 

Many diseases, as the exanthemata, usually occur but once in the 
same person, and, therefore, in the diagnosis of obscure cases, if a his- 
tory of their occurrence has been ascertained, they can be excluded in 
the count. Others recur from time to time, as croupous pneumonia, 
chorea, acute rheumatism, and tonsillitis. The history of a previous 
attack of a certain disease may point to the nature of a second attack 
which otherwise may be obscure. Some diseases, as rheumatism, 
syphilis, and gonorrhoea, have pronounced sequelae. Knowledge of 
the occurrence of the primary disease may solve doubts as to the nature 
of the sequela?. 

Infectious diseases lead to forms of neuritis and to brain affections, 
or to inflammations of organs. The seat of the specific inflammatory 
process varies in different diseases. After measles we find the mucous 
membranes impressionable ; and after scarlet fever, the serous mem- 
branes, the ears, the kidneys liable to inflammation. The history of an 
attack of hepatic or renal colic may point to the diagnosis of an 
otherwise obscure process in the liver or kidney. 

The history of injury must be sought for in brain and spinal affec- 
tions. The occurrence of a surgical operation in the past may point to 
lesions for which it was resorted to, which again may be the source of 
disease. 

The History of the Present Disease. 

Scope of Inquiry. The history of the present disease includes an 
account of the sufferings of the patient, which I have said are the sub- 
jective symptoms, of the duration of the disease, of its mode of onset, 
and of the evolution of its symptoms up to the time it was seen by the 
physician. The patient also gives an account of such objective symp- 
toms as could be noted by him, as swelling of the legs, the date of its 
commencement, mode of onset, and progress. In the case record the 
history to the date of examination is first recorded, and then the sub- 
jective symptoms are noted. The same order will be followed in the 
text. Practically, it is better to learn the symptoms on account of 
which the patient applied for treatment, and, with them as a guide, to 
inquire into the date of origin and mode of development of the disease. 



30 GENERAL DIAGNOSIS. 

Method of Inquiry. The history and subjective symptoms are best 
learned in the language of the patient. If the memory fails or the 
symptoms are not clearly narrated, judicious questions will suffice to 
complete the story. Leading questions must not be put until the 
patient's own account is fully given. 

Often the patient will be too voluble and introduce irrelevant matter, 
or too taciturn from modesty or a desire to conceal facts, as when illegit- 
imately pregnant. While much time is lost in listening to a prolix 
account of sufferings, the student will do well at first to bear with the 
patient, for it gives him the opportunity to study character, observe 
the mental and emotional characteristics of the patient and the expres- 
sion of the countenance. To suppress the loquacious, free the tongue 
of the silent, gather scintillations of intelligence out of the dense clouds 
of ignorance, requires knowledge of human nature of a high degree, 
acquired only by long practice. (Allied difficulties have been discussed 
in the paragraphs devoted to the family history.) Indeed, the wonder- 
ful faculty of seeking information in this manner has been the capital 
of many physicians of large practice. It is by this means and by 
tricks that the charlatan plies his vocation. A favorite method of the 
quack, after a few words from the patient, is to tell him how he — the 
patient — feels. They have some knowledge of the march of the 
disease, and portray its full development to the surprised and credulous 
victim. Elsewhere (see Subjective Symptoms) the reliability of such- 
data is discussed, and the student must not for one moment consider 
the data obtained by inquiry as of equal value with those obtained by 
observation — the former is the mere skeleton of the diagnosis. 

It is particularly important to secure a chronological order of events 
in the disease. They are essential and logical and throw much light 
on the progress of the affection. The diagnosis is much easier if such 
sequence is followed. Of course, there are circumstances when only 
the minimum amount of information of this character can be secured. 
The patient may be unconscious, or in a convulsion, or unable to speak 
from dyspnoea. It then becomes necessary to rely on the testimony of 
friends or to gather the information from the circumstances that 
surround the patient. 

Mode of Onset and Duration of the Disease. It is well to learn 
if the onset of the disease was sudden or gradual. If the former, the 
most striking phenomena are to be ascertained — a chill, convulsion, 
sudden pain, sudden vomiting, a profuse diarrhoea — each points to lines 
of further inquiry. If the latter, did it follow upon an acute illness, 
or did each symptom gradually increase in intensity, and as each week 
or each month passed by new phenomena creep into the symptom com- 
plex. We thus learn if the affection under consideration is acute or 
chronic — its duration. It must not be forgotten that certain affections 
may be two or three days — or, on the other hand, as many weeks — in 
developing, as typhoid fever, which, nevertheless, is acute. It must 
be remembered, also, that diseases may have sudden acute expressions, 
and that a chronic disease may be in existence a long time without the 
patient's knowledge. An acute colliquative diarrhoea or a convulsion 



THE DATA OBTAINED BY INQUIRY. 31 

is often the first intimation of a chronic nephritis, and an attack of angina 
pectoris the first symptom of organic heart disease of long standing. 
To appreciate the relationship of acute to chronic disease, or of acute 
phenomena to chronic morbid processes, requires a full knowledge of 
the processes of disease. 

Evolution of the Disease. In making inquiry concerning the evo- 
lution of the subjective symptoms, the frequency, duration, character, 
and degree of severity of each symptom, and its relationship to the func- 
tion of the organ apparently affected, must be inquired into. Thus in 
the case of pain in the abdomen, we must learn its character, its fre- 
quency, its duration," its intensity, and its location, and whether asso- 
ciated with functional disturbance of any of the viscera in which the 
pain presumably has its origin. Or, if there is frequency of micturi- 
tion, the length of time the symptom has been present, the degree of 
frequency, the time in the twenty-four hours when the micturition is 
most frequent ; its relation to food, exercise, or emotions ; the charac- 
ter of the act of micturition, and its association with other evidences of 
functional disorder or organic disease of the genito-urinary tract. 

Having ascertained the full story of the patient, including all data 
obtained by inquiry, special attention must be paid to the sufferings or 
complaints of the moment. They must be further inquired into in the 
manner above indicated. They may have been detailed in the begin- 
ning ; but information obtained from an account of the evolution of the 
disease or the previous history will require a repetition, with the put- 
ting of fresh questions or control questions. Having obtained the 
chronological account of the factors of life and of disease, we are prepared 
to examine into the significance of subjective symptoms. 

The steps thus far taken in the diagnosis are four in number. While 
considerable that is not essential may be gathered, the very gleaning 
of the facts enables the student to acquire objective information from 
the speech, the gesture, the expression, etc., of the highest value. 
Moreover, the facts ascertained are of value in determining a line of 
treatment to be pursued which will be scientific and rational, for in 
addition to the diagnosis the causal factors of the disease are often 
found. 

To repeat, preceding the fifth and final step in the diagnosis, the data 
secured by inquiry — (1) the social history, (2) the family history, (3) 
the history of previous diseases, (4) the history of the present disease — 
must be fixed in the mind. Marshalling the facts thus obtained in 
orderly procession, we are enabled to systematically add the facts of the 
present condition. Consideration of the data thus secured leads, by 
inductive reasoning, to the desired conclusion — a diagnosis. 



CHAPTER III. 

THE DATA OBTAINED BY INQUIRY— {Continued). 

The Present Condition : The subjective symptoms — Mode of determination — Their 
fallacy — Their value. Feigned disease. Local subjective symptoms — General 
subjective symptoms. 

We now come to the final step in the investigation — the determi- 
nation of the present condition, the status prcesens. To determine the 
present condition inquiry and observation are necessary. This chapter 
and the succeeding one will discuss only the data obtained by inquiry. 
They, therefore, include the subjective symptoms other than those that 
pertain to special organs or systems. Caution, circumspection, adroit- 
ness, combined with tact and good judgment, are more essential to 
secure a true account of the patient's sufferings even than to obtain a 
correct history of the disease. 

The subjective symptoms are expressive of the sensations of the patient, 
and vary in accordance with the sensibilities of the individual affected. 
Thus acute pain may apparently represent a severe process in one, 
while in au other the same severity of process may be represented by 
the minimum amount of pain. It is well known that individuals of 
one nationality bear pain with greater fortitude than individuals of 
another. 

Caution. The patient. Individuals vary not only as to pain 
sense but as to other subjective symptoms. The morale is shattered 
in some more readily than in others — thus, for instance, oppression of 
the pr*cordia may strike terror to some, while to others it would be 
simply a sense of discomfort. Moreover, subjective symptoms are con- 
stantly before the patient while in distress, if only in the mind's eye. 
Because of this perturbed state they grow in magnitude rather than 
diminish. We must study them from many points of view. The mode 
of onset, frequency, degree, and character of the symptoms must be 
inquired into. The competency of the witness under the circumstances, 
from lack of accurate noting of symptoms, failure of memory, varying 
degree of susceptibility to impressions, etc., may well be doubted. 

The physician. But not only does the varying l ' personal equation " 
of the patient render subjective symptoms fallacious, the same factor 
in the physician contributes to the fallacy. The latter may have unfor- 
tunately formed, by hearsay regarding the patient, a preconceived notion 
of the nature of the disease ; or from personal bias in favor of particular 
diseases, on account of narrow lines of study or lack of breadth of view 
of pathological processes, he may set out to prove a theory rather than 
to establish a fact. In either case, by leading questions, by placing 
emphasis on certain parts of the testimony, the subjective symptoms 
can be juggled with and made to tell any but the truthful story. 



THE DA TA OB TAIN ED B Y INQ UIR Y. 33 

It is to be remembered that it is our province not only to ascertain 
the cause of suffering in the sick, but also to detect the flaws in the 
testimony of him who would feign sickness. The malingerer utilizes 
subjective symptoms to hide his deception because they cannot be seen, 
felt, weighed, measured, or ascertained by hearing. 

Feigned Disease. To detect feigned sickness demands much acu- 
men on the part of the physician. He must not only be able to make 
an accurate and exhaustive objective examination of the patient, but be 
alert to appreciate surroundings and conditions. Feigning may be 
suspected if there is a motive, as in the case of prisoners, pension 
applicants, students at school or college, and persons who hold policies 
of insurance indemnifying in case of sickness. The hospital ' ' beat " 
thus plays upon charity. 

If sickness recurs frequently without definite cause, while the sub- 
jective symptoms are mild and quickly relieved and the objective symp- 
toms negative, the use of instruments of precision will detect the 
malingerer. With their aid we can usually find out if the subjective 
and objective phenomena tally. The failure of such tally proves the 
deception. The thermometer frequently exposes the deception, as fever 
can rarely be simulated, although tricks Avith the thermometer may be 
carried on. A favorite method is to rub it, and thus cause the mercury 
to rise. Frequently the suspected person must be placed under close 
surveillance, unknown to him, and tricks of all sorts, suggested by the 
surroundings and circumstances, played upon him to make him unwit- 
tingly testify to his deception. 

The student will learn later that there is a mimicry of disease, and 
that in certain nervous affections the simulation of subjective symp- 
toms is its chief role. In hysteria, subjective and objective symptoms 
are masked. Long experience and acumen are required by the physi- 
cian to unmask the deceptions. The age of the patient, the sex, the 
state of the emotions, the varying expressions of the symptoms (under 
varying circumstances) — with attention fixed or removed — the mobility 
of the symptoms under excitement or emotional disturbance, the lack 
of harmony between functional disorder and organic change, are the 
elements to be considered in order to fathom the mysteries. Often 
anaesthesia must be induced in order to dissipate simulated tumors, 
relax rigid joints or contracted limbs. Magnetism, electricity, and 
other tests are likewise employed. In the chapter on Hysteria its 
manifold expressions will be adverted to, and it will be seen that func- 
tional disorder of almost every organ or special sense is simulated in 
this affection. Organic processes even are imitated, as joint inflamma- 
tions, peritonitis, and other grave conditions. 

Value of Subjective Symptoms. Notwithstanding the fallacy of 
subjective symptoms in that they may be feigned or mimicked, they are 
valuable evidences in the hands of the scientific inquirer. If the 
patient is a good witness their value is much enhanced. He must be 
intelligent and truthful. His testimony is of value if he can array in 
logical order the sequence of symptomatic events which culminated in 

3 



34 GENERAL DIAGNOSIS. 

the condition for which he seeks relief. If he can clearly narrate the 
events in his past life, or in the lives of his ancestors, which appertain 
to physiological aberrations, his story is an aid to the searcher for truth. 
If, with this, the doctor is possessed with a scientific turn of mind, 
considering evidence without allowing previous conceptions to influence 
him, capable of discerning the truth and discarding the false, of an- 
alyzing and weighing statements, and of appreciating their relationship 
to what is known of morbid processes, the patient's statements of sub- 
jective symptoms are of value in the discernment of disease. 

Local Subjective Symptoms. The symptoms of which the patient 
complains may be general or local. The former will be briefly consid- 
ered in this section ; the latter will be discussed in the respective sec- 
tions devoted to disease of the various organs to which the subjective 
symptoms refer. They are symptoms due to functional disturbances 
of the respective system that is the seat of disease, as dyspnoea or cough 
in diseases of the respiratory system, anorexia or nausea in diseases 
of the digestive system. An exception will be made in the case of pain. 
While there may be such general suffering as to constitute pain (gen- 
eral soreness, aching, rhachialgia), yet the symptom has its point of 
origin most frequently in some local disorder. Notwithstanding this 
fact, however, as it is a symptom common to so many affections, and as 
general rules apply to the recognition of its multitudinous forms, a brief 
section will be devoted to its study. 

General Subjective Symptoms. The general subjective symptoms 
— that is, the abnormal and disagreeable sensations which extend more 
or less over the whole body, or are referable to more than one organ 
or apparatus — are few in number and are not diagnostic of any partic- 
ular affection. They are at times the only symptoms complained of by 
the patient, and require investigation. They include abnormal sensa- 
tions of strength or weakness, general numbness or tingling, and general 
paresthesia of all kinds ; general vasomotor disturbance, causing sen- 
sations of heat, such as occur in flashes, or sensations of cold, from mild 
chilliness or " creeps " to the pronounced chill or rigor, sudden perspi- 
rations, general throbbings or pulsations, and general discomfort, to 
which the term nervousness is applied. Irritability, disorders of sleep, 
and the more distinct nervous manifestations above mentioned, will be 
referred to in sections on nervous diseases, and particularly discussed 
under Hysteria and Neurasthenia. 

A feeling of strength, or the idea of an ability to perform great feats 
of strength or endurance, or a great mental feat, is a subjective symp- 
tom that is dwelt upon by the patient who is developing or passing 
through certain stages of paretic dementia. It is accompanied by other 
evidences of exhilaration. Exhilaration attends chlorosis and forms of 
hysteria and neurasthenia, the physical or mental exhibition of strength 
taking place in the after part of the day and evening or upon undue 
excitement. Corresponding depression usually follows. 

A sense of weakness, or exhaustion, or of fatigue is often complained 
of. If an absolute demand is made upon the bodily strength it can 



THE DATA OBTAINED BY INQUIRY. 35 

respond, but otherwise it is not exerted. The patient complains of 
being more tired in the morning than upon retiring, or of a sense of 
inability to perform accustomed or special duties. Mental depression 
usually attends the phenomena. It is due to neurasthenia generally, 
but is a frequent accompaniment of and dependent upon the forms of 
toxaemia to which malaria, gout, and rheumatism belong ; of the 
toxaemia of certain varieties of indigestion, of tobacco, alcohol, and 
other narcotic poisons (tea or coffee), and of mineral poisons. The 
same sense of fatigue attends the prodromal stage of the specific fevers. 
It has been a symptom observed frequently of late in the sequential 
period of influenza. 

The sensation of weakness must not be confounded with true weak- 
ness or muscular prostration. While the patient is aware of its pres- 
ence, it is well to consider it under the objective phenomena of disease, 
for it is a readily recognized sign of disease. 

Numbness, or tingling, or burnings may be general or local. It is a 
common form of paresthesia, to be discussed in the section on nervous 
diseases. It must be remembered that, while a disorder of sensation, 
it is due to morbid conditions outside the pale of the nervous system. 
It may be of reflex origin, from irritation at a distant point, or it may 
be and usually is due to toxaemia, as lithaemia. Other subjective vaso- 
motor disturbances that are of frequent occurrence are likewise mani- 
festations of nerve disorder from reflex or toxic causes. Flushings, 
and a constant sensation of heat, with or without perspiration, which 
attend the perturbation of the menopause, are common in uterine dis- 
orders and in chronic gastritis. 

The student will learn that the curious manifestations to which refer- 
ence has been made are all evidences of ill health, of a depressed 
vitality, of a condition in which there is malnutrition, poverty of 
nerve-force, and lack of blood-richness (anaemia). There may be 
peripheral irritation or a toxaemia, but the under-current of ill health 
is the fundamental derangement. 

Chill and fever. Both are subjective as well as objective phenomena, 
but as one can be accurately estimated by an instrument of precision 
(thermometer), and as both are generally associated, the discussion of 
them will be postponed. (See Objective Signs.) 

The abnormal sensation of cold or of heat will be discussed in the 
chapter on Nervous Diseases. 



CHAPTER IV. 

THE DATA OBTAINED BY INQUIRY— (Continued). 
PAIN. 1 

Definition. Pain is a general term used in medicine to describe a 
number of subjective symptoms connected with morbid processes. It 
may be defined as a sensation which produces on the part of the organ- 
ism, as a whole, the desire to abolish or escape from it. It is the 
expression in consciousness of injury to the peripheral or central ner- 
vous system by irritation or lesion ; at times the central end of the 
peripheral nerves may be the seat of irritation, causing so-called referred 
pains. This definition, however, fails to include the hyperesthesias, 
the hyperalgesias, and all simulated pains. But the latter are to be 
included in this section, on the ground of clinical convenience, whilst 
the two former are only of significance as conducing to the production 
of pain. 

Pathology. The pathology of pain is generally believed to be a 
state of impaired nutrition, and hence of injury, gross or microscopic, 
either at the periphery or in the afferent nerve tract. The cause may 
be purely functional, as, for example, when pain is due to the over- 
stimulation of the tract by its normal stimulus and its consequent ex- 
haustion ; or to strictly local conditions, as pressure, injury, or inflam- 
mation ; or to systemic conditions acting locally, as the neuralgias of 
anaemia. There is also the so-called sympathetic or reflex pain, due to 
irritation in a part removed from the locality to which the sensation is 
referred. 

Pains in reference to the general nervous system may be classified 
according to the localization of the lesion into (1) peripheral, (2) cen- 
tral, and ( 3) general. Peripheral pains are those due to some alteration 
either in the structure or nutrition of the peripheral nerves, and the 
disturbance may be situated at the sensory terminations, or anywhere 
in the course of the nerve or in the nerve-roots. Pains due to causes 
situated in the latter place are usually perceived at the peripheral dis- 
tribution of the nerve, and are, therefore, spoken of as referred pains. 

1 Pain is treated in a suggestive manner, and so much space is given to it because 
it is too frequently improperly managed. Its cause is never thoroughly investigated. 
Anodynes are given for its relief, thus too frequently creating victims of the morphine- 
chloral-, or other habit The following articles are suggestive : Head : On Disturb- 
ances of Sensation, with Especial Reference to the Pain of Visceral Disease, Brain, 
vol. xvi., Part I., 1893; Ross: Brain, 1888: Mackenzie: Medical Chronicle, 1888; 
Mackenzie: Points Bearing on the Association of Sensory Disorders and Visceral 
Disease, Brain, vol. xvi., Part III., 1893. Also, papers by Starr. See Section on 
Nervous Disorders. 



THE DATA OBTAINED BY INQUIRY. 37 

The nature of central pain is not at present clearly understood. Cer- 
tain cases have been reported in which pain has been perceived in one 
part of the body, usually an extremity, and at post-mortem no lesion 
whatever could be found in any portion of the afferent nervous system 
coming from this region. Lesions, however, have been found in these 
cases in the brain itself, and it is supposed that these are responsible 
for the painful impression. General pains are those due to some toxic 
condition of the blood, or impairment of the nutrition of the nervous 
system as a whole, and manifested as pain in the regions of least resistance. 

Cause. Conditions acting upon the peripheries of the sensory nerves 
are injuries or disease of the surfaces or of the viscera. Conditions 
acting upon the nerve in its course may be either internal or external. 
Among the internal causes are the chronic and acute forms of neuritis. 
Among the external causes are tumors, perineural inflammatory pro- 
cesses, or anything causing mechanical injury to the nerve itself. 
Nerve roots are usually involved in intraspinal growths, in spinal men- 
ingitis, and, occasionally, as a result of disease of the vertebral column. 
The lesions causing the central pain are embolism, hemorrhage, soften- 
ing, inflammatory processes, tumors, and injuries. General causes are 
the anaemias, the intoxications, the infectious fevers, and perhaps certain 
drug habits, as morphia ; although it is usual to include the pains com- 
plained of by opium eaters among those due to simulation. 

Variations in Disease. Pain is, perhaps, the most variable symp- 
tom in disease. It ranges from a sensation of mere discomfort, as the 
dull ache of chronic lumbago, to the stabbing pain of pleurisy, or the 
intolerable anguish of heart-pang. It is at times compatible with the 
highest mental endeavor or the severest physical exertion, or the whole 
energy of the organism is absorbed in resisting it. It may be definitely 
localized in any part of the body, in any of the tissues, or distributed 
over an ill-defined area. 

The Recognition of Pain. 

The Mode of Expression. As a rule, the physician learns of its ex- 
istence by the complaint of the patient. Thus he learns more or less 
accurately its location, character, degree, and duration, and usually 
something concerning its causation. But the value of this source of 
information is variable. The patient may be voluble, and describe too 
much ; or taciturn, and shrink from admitting his suffering ; or ignorant, 
and unable to give a clear account. Fortunately, there are other ways 
by which suffering is expressed which may be grouped among the 
objective symptoms. They are : (a) Facial expression, the most common 
interpreter of the emotion, is far more reliable. The tense and drawn 
lineaments, the clinched jaws, the dilated pupils, the livid countenance, 
make a picture of agony which, with the labored respiration, the general 
shrinkage of the body, are unmistakable. (See Chapter VII., The Face.) 
Or, in a less intense form, the shrieks and struggles or the groans of 
more prolonged suffering are no less impressive in their suggestiveness. 
(6) Not less characteristic are the various postures assumed ; the sudden 
fixity of heart-pang ; the retracted head of meningitis ; the immobile side 



38 GENERAL DIAGNOSIS. 

of pleurisy ; the crouching attitude or restlessness of colic ; the flexed 
thighs and immobile trunk of peritonitis ; the shoulder drooping to the 
affected side in renal colic ; or the bent knee of arthritis, (c) Further, 
there are certain reflex actions that are associated with local irritations ; 
thus the closing of the eyelid on irritation of the conjunctiva ; the sneeze 
or cough on irritation of the nasal or laryngeal mucous membrane ; the 
erection following irritation of the urethra ; or even the limp character- 
istic of pain on moving or resting the weight of the body on an affected 
limb. Then there is the sudden shrinking of the whole body, the 
attempt to defend, or the sudden movement of the hand to the affected 
part, or the sudden jerking away of the part itself if the act be possi- 
ble ; these are true reflexes, and sufficiently diagnostic of local suffering. 
It scarcely need be mentioned that in children, in the insane, in persons 
unable for many reasons to communicate their thoughts, the expression 
of pain is of the greatest diagnostic value in determining its seat, (d) The 
phenomena of the associate morbid processes may serve to indicate the 
occurrence of pain and its seat. Thus pain is one of the cardinal symp- 
toms of inflammation ; it is commonly associated with nerve-injury ; it 
is frequently accompanied by local flushing or herpetic eruptions in 
neuralgia. 

Sources of Error. In estimating the presence or absence of pain, 
or its degree, certain control conditions must be borne in mind. Un- 
fortunately pain is one of the most unreliable of symptoms. It is neces- 
sarily a subjective symptom, with, in all probability, qualitative as well 
as quantitative variations. The particular degree in either respect is 
of importance in diagnosis, and as only the roughest means, if any, are 
available to estimate it objectively, the physician is compelled to rely 
almost wholly upon the statements and appearance of the patient. His 
statement can err in two directions : the patient can exaggerate his 
sufferings or depreciate them. The tendency to exaggeration is most 
marked in the nervous temperament ; in those suffering from chronic 
disease of long standing ; in those accustomed to in-door and mental 
labor ; in women and in the young. The tendency to depreciation is 
most marked in the phlegmatic temperament ; in those accustomed to 
hardship, especially if of small intellectual development ; in men and 
in the aged. Both tendencies are to be corrected as nearly as possible 
by observing the associated symptoms and the character of the patient, 
and by skilful questioning. The appearance can deceive because of 
undue susceptibility to suffering on the part of the patient, or unusual 
inhibitory power. There can be no question that painful stimuli, 
usually easily borne, in some produce almost unbearable misery. Such 
exaggerated sensibility occurs in the emotional, in the weak and debili- 
tated, and in the delicately nurtured. Mental association is a powerful 
factor ; it is well known that soldiers, who in the heat of battle disre- 
gard serious and necessarily painful wounds, will suffer intensely under 
the probably less painful offices of the surgeon ; and it is unfortunately 
a common experience that the surroundings of the operating-room make 
the most trifling and briefest operations full of serious suffering. 
Habitual use of opium seems to increase this susceptibility in a remark- 
able manner. Patients will even submit to operations for the relief of 



THE DATA OBTAINED BY INQUIRY. 39 

a supposed ailment that is found to have no physical basis ; and this 
occurs in cases in which there is no reason to believe that the pain 
is simulated as an excuse for the indulgence. Moreover, a pseudo- 
neuralgia is wont to occur in victims of the morphine habit. It may 
simulate a gastralgia or an intestinal colic. The writer has seen an 
innocent victim of morphine suffer from pseudo-hepatic colic, with- 
drawal of the drug causing subsidence of the periodical attacks of pain 
and vomiting. Inhibition is a much more serious source of error, for 
while undue attention to one part is only reprehensible when practised 
to the neglect of others, a patient who disregards pain may fail to direct 
attention to the real seat of disease. It is sometimes exercised to a 
most remarkable degree. The stoicism of the American Indian under 
torture is attested by many observers ; certain religious sects among 
the Hindus habitually afflict themselves in the most ingenious ways ; 
the early Christian martyrs rejoiced in misery. It is common to find 
this disregard of pain among those exposed by occupation to discom- 
forts and injuries, and the Teutonic and Slavic races appear to possess 
it in a higher degree than the Celtic or Semitic. Shock either, inhibits 
pain or diminishes the normal response to it. Lastly, and by no means 
to be neglected, a most common source of error is undue credulity or 
skepticism on the part of the physician, for he may be deceived by an 
eloquent and persuasive complaint, or discredit true suffering. 

Simulated Pain (see Feigned Disease) is to be recognized by the 
existence of a motive for deception. The simulation is common enough 
in those who seek damages for injuries, or in those who have a morbid 
craving for sympathy and attention. Its detection depends upon the 
skill of the physician, who, by distracting the attention from the part 
complained of, observes that the pain disappears, or, on the other hand, 
that pain is admitted in a part to which attention is directed ; more- 
over, the physician observes an absence of adequate physical alteration, 
and usually inconsistency in the symptoms, for the malingerer is seldom 
able to simulate a correct clinical representation for any length of time. 
Especially in the latter case is the observation of the invalid's sur- 
roundings of considerable importance. The so-called hysterical mask 
is of much value, for the bitter complaints and the placid or even smiling 
features cannot fail to strike the observer by their incongruity. True 
hysteria is apt to be deceptive, and more than one humiliating failure 
is recorded of even the most skilful of our craft. The difficulty is in- 
creased because actual physical changes occur, as amaurosis with dila- 
tation of the pupil, contracture and induration about the joints, unques- 
tionable anaesthesias, and palsies. True hysteria is often to be detected 
only after prolonged and painstaking study of the case ; the careful 
exclusion of organic visceral disease ; by the absence of the character- 
istic symptoms of the nervous degenerations, such as ankle-clonus, or 
altered electrical reactions, or changes of the fundus oculi ; and often 
by the impossibility of associating the sensory lesions with the known 
anatomical distribution of the nerves. 

Objective Investigation of Pain. In order to estimate accurately 
the diagnostic value of pain, the statement of the patient must be cor- 



40 GENERAL DIAGNOSIS. 

rected by his expression, posture and manner, and the apparent nature 
of the disease. Pain is one of the cardinal symptoms of inflammation ; 
vasomotor and muscular disturbances are often associated with neural- 
gia ; any morbid condition exerting pressure on a nerve-trunk, as a 
neoplasm, callus, etc., commonly causes pain. Hence if the objective 
phenomena of these disorders are present, they lend color to the com- 
plaint of pain, and, if not, they should be inquired for. Attempts have 
been made to estimate the acuteness of the pain-sense with scientific 
accuracy, or at least to secure a practical method for measuring its 
varying intensity in different localities in the same case. Bjornstrom, 
of Upsala, has contrived a pair of forceps that compress a fold of skin ; 
the amount of pressure required to produce pain, which can be read 
from a scale, indicates the degree of sensibility or rather resistance to 
painful impression. Another instrument, Buch's, accomplishes the 
same thing by direct pressure, and hence can be used over the super- 
ficial nerve-trunks. Another method more generally available is the 
application of an induced faradic current of variable strength — single, 
naked-wire electrodes being best for this purpose. The common clinical 
method, by far the most inaccurate and only applicable in cases of 
marked analgesia, is a pin or needle forced through a fold of skin. No 
method has yet been suggested for even the approximate estimation of 
the acuteness of sensibility to internal pain, and it must still be left to 
the judgment of the patient. 

The Clinical Value of Pain. The presence of pain is recognized 
by the above-mentioned circumstances. Its degree, with the limita- 
tions indicated, has been estimated. Its clinical value is then to be 
considered. From what has been said above, the converse of many of 
the propositions is true. By pain and the mode of its expression we 
can judge of the character, temperament, and nervous susceptibility and 
perturbability of the patient. It aids us in the recognition of hysteria 
and helps to detect the malingerer. We learn the patient's capability 
of resistance, and hence, in a measure, his strength. We learn the 
quickness of receptivity in consciousness of the peripheral irritation, or 
the degree of intelligence, or the amount of stupor ; or, if conditions 
are present which usually cause pain, its absence may show disease of 
the conducting paths to the brain. Further, the absence of pain under 
the above circumstances points to the occurrence in the local process of 
such change as has destroyed peripheral nerve-endings. Thus, when 
pain ceases in dysentery gangrene has ensued. In intestinal obstruc- 
tion its cessation indicates the same process. In profound shock pain 
is not complained of ; the amount of pain, therefore, indicates the 
degree of shock. Hence, in peritonitis, in which shock frequently 
occurs, pain may be wanting entirely. The abdominal surgeons welcome 
its occurrence after an operation, as it indicates the absence of shock. 

While the above lessons, from the presence or absence of pain, are 
not to be under-estimated, the value of pain to the physician is from 
the stand-point of diagnosis. By this symptom we may be enabled to 
determine the location of disease and the nature of the causal morbid 
process. 



THE DATA OBTAINED BY INQUIRY. 41 

(A) The location of the disease is determined (a) by the seat of the 
pain and (6) in part by the mode of expression. The mode of expression 
also indicates its point of origin in a general way and its probable cause. 
They are (1) the facial expression, (2) the posture, (3) the reflex actions, 

(4) the associate phenomena. They need not be referred to again. 
(See page 37.) (B) The nature of the causal morbid process is judged 
by the study of pain from various stand-points. Thus in the consider- 
ation of the symptoms of pain we must learn (1) the mode of onset, 
(2) the duration, (3) the time of occurrence, (4) the character or variety, 

(5) the location, (6) the modifications produced by pressure, tempera- 
ture, rest, motion, posture, electricity, drugs, and climate. 

1. Mode of Oxset The mode of onset of pain is in the majority of 
cases an indication of the acuteness of the morbid process. (A) The 
onset may be sudden, as (1) in gout or acute inflammations of serous 
membranes, as pleurisy or peritonitis ; (2) in certain headaches, particu- 
larly in those of congestive or emotional origin ; (3) in acute obstruction 
of canals ; (4) in contraction of muscular structures in their effort to 
remove a foreign body, as in the intestines, the gall-ducts, the vermi- 
form appendix, the ureters, bladder, or uterus ; (5) in rupture of the 
structure in which it is developed. Here we have the most typical 
sudden pain. Thus, in rupture of an aneurism or of the heart there 
is sudden, sharp pain. In rupture or perforation of the stomach or 
intestines, or any of the hollow viscera, this character of pain arises. 

(6) Sudden pain also occurs in certain neuralgias or neurosal affections. 
It is seen in its most striking form in angina pectoris, locomotor ataxia, 
and in acute brow-ague, or trigeminal neuralgia. (B) The onset 
may be gradual, and may be associated with continuous increase in 
intensity or variation. Such onset indicates that the process is one of 
slow development and not attended by a " solution of continuity," as 
from rupture or tear. It usually occurs in various forms of rheuma- 
tism, in inflammations of muscles and of mucous membranes, in chronic 
inflammations of serous structures, in chronic bone disease, and in 
slowly developing mechanical pressure, as tumors. 

2. Duration The duration of the pain indicates the acuteness or 
chronicity of the causal morbid process, (a) Pain of short duration 
is seen in the affections in which it develops suddenly (see Mode of 
Onset), in acute serous inflammations, and in neuralgias, (b) Pain of 
long duration, if constant, is usually due to organic lesions ; if inter- 
mittent, it may be due to neuralgia. Pain that is continued over a 
long period of time excludes the sudden accidents that were previously 
mentioned, unless change in the character of the pain takes place. 

Pain is also divided, as to duration, into temporary and constant 
pain. Temporary pain indicates an abeyance or relief of the morbid 
process, while the constant pain points to its continuance. Constant 
pains are seen in bone affection, in inflammation of muscles, in reflex 
pains due to chronic disease elsewhere, as the backache of uterine 
disease, or the inframammary neuralgias from the same cause. Pain 
may also be intermittent or remittent, paroxysmal and periodic, [a) In- 
termittent and remittent pains are characteristic of neuralgias, or 
point to a functional origin ; they are recurring because the cause 



42 GENERAL DIAGNOSIS. 

which superinduces them is again operative. Thus recurring head- 
aches due to eye-strain may be intermittent or remittent in the sense 
that they occur only when the eye is used. Attacks of such pain recur 
over a long period, (b) Paroxysmal pain is the form which occurs 
when there is obstruction of channels, as the gall-ducts in biliary colic, 
the intestines, the uterus, and the ureters in the various forms of colic 
to which they are liable. The paroxysms of pain recur in the course 
of the attacks, (c) The term periodic is applied to pains that occur at 
distinct intervals. Pain that is periodic has frequently for its cause 
malaria in some form. The toxic headaches and nerve headaches, as 
migraine, are often periodic. (Consult Headaches.) 

3. The Time of Occurrence. The time of the occurrence of 
pain is important. Pains may occur in the daytime, or during the night 
exclusively. Nocturnal pains are common in syphilis. They are usually 
due to periosteal inflammation. Diurnal pains are usually reflex from 
functional disorders. Some pains, as headache due to cardiac weakness 
and to forms of anaemia, are present during the day, because the patient 
is in the upright position. They disappear in the recumbent position, 
and hence are absent at night. 

The time-relation of pain to functional acts is of importance. Thus 
in gastric pain its relation to the taking of food is to be ascertained. 
Pain coming on before meals is gastralgic ; occurring after meals, it is 
due to ulcer or cancer, sometimes to indigestion. Chest pains, in- 
creased by the act of breathing, are muscular or pleuritic. 

4. Character. Pain may be sharp, lancinating, or stabbing ; it 
may be throbbing, or it may be dull. Sharp, lancinating, or stabbing 
pain is usually due to inflammation of serous membranes, to colic in 
various forms, and to forms of neuralgia. Cutting pain is a sharp form 
that occurs in flatulent colic. Throbbing pain is usually associated 
with acute inflammation, whether superficial or deep. It may be 
rhythmical with the pulsations of the heart. Dull pain is due to slow 
chronic inflammation in the bones and in the viscera ; it is the pain of 
myalgia and of fatigue in the muscles. It may be of an aching charac- 
ter. But aching pains may also be general ; they are found among the 
prodromata of the acute diseases, attend and follow a chill, and occur 
in most characteristic form in influenza and dengue. Pressing pain is 
complained of when it attends an attempt to remove material from the 
viscera, as the passage of water when the bladder is inflamed ; the 
passage of faeces in dysentery. The term tenesmus is applied to it, 
so that we have vesical tenesmus and rectal tenesmus. The passage 
of clots or other material from the uterus is attended by pain with 
pressure or " bearing-down/' as it is termed. 

Nature of the Disease. Finally, the character of pain is often an 
indication of the nature of the disease as well as of the tissue affected : 

1. Thus boring and constant pain is seen in bone and periosteal disease. 

2. Soreness or aching in muscular affections. 3. The pain is sharp and 
stabbing when serous membranes are affected. 4. Smarting and burn- 
ing, or, perhaps, dull and sore when mucous membranes are inflamed. 
5. Burning or itching in affections of the skin. 6. Dull and usually 
constant in visceral affections, although in malignant disease of various 



THE DATA OBTAINED BY INQUIRY. 43 

organs it may be sharp and paroxysmal. 7. Aching, burning, and 
throbbing in the nerve-trunk and its distribution, with tenderness, 
commonly indicate neuritis. 8. A sense of swelling, distention, or 
bursting attends the pain of obstructions of hollow viscera, as in renal 
or hepatic colic. 9. Rending or tearing pain may be complained of 
when a hollow viscus or sac is ruptured, as notably in the rupture of 
the sac of extra-uterine pregnancy. (See " pain crises/ 7 page 44.) 

5. Location and Distribution. It may be of questionable advan- 
tage in some cases that the localization of pain generally indicates the 
situation of the morbid process. Too often an apparently adequate 
explanation of the symptoms may thus be found, whilst other pathologi- 
cal changes may be overlooked. But, on the other hand, the condi- 
tion to which attention has been called by the pain might, on account 
of its obscurity or unusual location, altogether escape observation. 

The location is, in general, an indication of the seat of the disease. 
It may be accepted as an almost universal rule that pain due to a local 
process is limited to the immediate or associated nerve-supply of the 
diseased region. This holds true even when the referred pains — that 
is, those felt in the associated nerve-supply — are as far distant from the 
site of the morbid process as the knee pain of coxitis, the shoulder pain 
of hepatic disease, pain in the neck from pericarditis or diaphragmatic 
pleurisy, the ear and temporal pain of lingual carcinoma, the pain in 
the legs from cancer or ulcer of the rectum, the testicular and thigh 
pain of renal colic, or the umbilical pain of vertebral disease. 

On the other hand, Hilton lays down the rule that pain in any part, 
in the absence of a local process, is due to exalted sensitiveness of the 
nerves of that part, and depends upon a cause remote from the painful 
area. The term sympathetic is applied to this group of pains. Further, 
Hilton remarks that pain on the surface of the body must be expressed 
by the nerve which resides there, and, hence, the cause of the pain 
must be situated between the peripheral termination and its central 
origin. This applies particularly to the pains which arise from disease 
of the vertebrae and the referred pains described above. As a corol- 
lary to this, in the investigation of the cause of pain, the nerve, its 
anastomoses, and the organs supplied by it should be investigated. 

But the pains may be general as well as local. 

1. General pains are due either to central or to peripheral dis- 
turbance of the nervous system by a poison circulating in the blood. 
This may be the poison of fevers, or it may be a rheumatic or gouty 
poison. It is seen in the common affection known as " cold," when 
the pains are probably myalgic. In syphilis, malaria, lead-poisoning, 
and toxaemias generally there is general pain, soreness, and fatigue. 
General pains are not confined to the muscles, but are also seated in 
the fibrous structures and bones. In their more severe forms such 
pains occur in dengue, and are known as u break-bone." 

2. Local pains may be (a) superficial or deep-seated ; (b) circum- 
scribed or diffused. 

(a) Superficial pains are due to involvement of the superficial nerves 
distributed to the skin or to the muscles directly underneath, or to the 
structures in close relation to the skin, as the peritoneum, the pleura, 



44 GENERAL DIAGNOSIS. 

or the pericardium. Deep-seated pains, when in the extremities, are 
due to bone disease ; when in the abdomen, to disease of the viscera, 
particularly inflammatory affections, to aneurism, or bone disease ; when 
in the chest, to disease of the aorta and mediastinum. 

(b) Circumscribed pain is always due to a small area of disease, or is 
reflex. Thus, in ulcer of the stomach the pain is usually circumscribed 
to a small area in the epigastrium ; in inflammation of the appendix, to 
the region of that structure. Diffused pain indicates involvement of a 
large area with less intensity of process than when circumscribed. 
When the pain is diffused, or, as it is sometimes called, radiating, over 
an area of nerve distribution, its point of origin may be found somewhere 
in the course of the nerve, either in the trunk or in one of its branches. 
Corollary: Given pain in a locality, study the nerve-supply of that 
region and the nerve anastomoses connected therewith. We learn much 
from the study of this distribution. The referred pains have been indi- 
cated (page 43). Among others, the pain of angina radiates down the 
arms. The pain of diaphragmatic pleurisy is referred to the front of 
the abdomen above the umbilicus. Radiating pains, however, are chiefly 
due to disease in the course of the nerve, the pain being referred to 
its trunk and terminal distributions, as pain in the foot in sciatica. 
Pain from pressure upon the nerves at their exit from the spinal 
canal is at the periphery of the nerves, as in the centre of the ab- 
domen, and not at the point of exit. Pain in this locality is frequently 
an indication of disease of the vertebrae, propagated by the sixth or 
seventh dorsal nerve. Pain between the shoulders is often due to 
aneurism which presses upon the vertebra?. (See Pain in the Heart.) 

Bilateral, symmetrical, and superficial pains indicate a central or bilat- 
eral cause ; while, on the other hand, unilateral pain implies a seat of 
origin which is one-sided. 

Peripheral Pain of Central Origin. We have referred to 
pains of the extremities or trunk due to central disease. In meningitis 
and other general organic affections of the brain and cord peripheral 
pains are frequent, and may be the earliest and most striking symp- 
toms. Indeed, it is very common to find patients with spinal-cord 
disease who have been treated for a long time for what was supposed 
to be rheumatism. The pains in the joints of central origin may be 
constant, or paroxysmal and lancinating when the disease is chronic. 
(See Character.) The cardinal rule, that all peripheral pains, without 
obvious local cause, should lead to an examination of the nervous 
system, must never be forgotten. The paroxysms of pain may be most 
excruciating, and sometimes cause collapse. They are known as painful 
crises. Pain may be complained of in various viscera, as well as in the 
joints. Sudden, intense pain, with functional disturbances of the affected 
viscera, occurs independently of any lesion of the part or of any apparent 
exciting cause. One class of the attacks is known as gastric crises. 
The pain is in the epigastrium, and is associated with vomiting. In 
another class laryngeal crises occur, with pain in the larynx and violent 
spasmodic cough, with dyspnoea. The pain extends over the shoulders. 
Or we may have rectal crises, with sensation of burning in that situation ; 
urinary crises, simulating renal colic, and genital crises. Pains, in 



THE DA TA OB TAINED B Y 1NQ UIR Y. 45 

crises, also occur in the muscles. Crises occur chiefly, if not entirely, 
in locomotor ataxia. They are distinguished from pain due to other 
causes by their sudden onset, their extreme severity, the absence of 
organic disease or local cause in the affected viscera, the sudden termi- 
nation, the normal condition between the attacks. 

6. Pain Modified by Pressure, Movement, Rest, or Mental 
Diversion. We also study pain under the influence of pressure, 
movement, temperature, rest, etc. Pain that is modified by pressure is 
generally superficial. It is usually of an inflammatory origin. The 
variety of the pressure gives some clue to the nature of the pain. If 
the pain is increased by pressure of the finger-tips, it is due to ulcer or 
inflammation when internal and to inflammation if external. Although 
of visceral origin, gastralgia and colicky pains in the intestine, which may 
be a neurosis, are relieved by pressure, particularly if the whole hand 
is applied. Pain from the dislocation of an organ, as a movable kidney 
or displaced uterus, or from dependent viscera, may be relieved by 
judicious pressure in the proper direction, so as to relieve the displace- 
ment. 

Pain from affections of the nerve-trunks can be distinctly localized 
by pressure in the course of the nerve-trunk, and particularly at the 
points where the cutaneous filaments of the nerves come through the 
fascia. These points in the thorax are along the vertebral column, in 
the axillary region, and anteriorly about the parasternal line — the points 
of Valleix. We distinguish neuralgias from myalgias by the presence 
of these tender points. Pain due to bone disease can frequently be 
distinguished in this way. By pressure or weight upon the head or 
shoulders we may ascertain if pain is due to vertebral disease. The 
presence of renal calculus or of gall-stones may be determined by the 
excitation of pain by pressure. 

Pain increased by movement points to an affection of the bone, 
muscle, joint, or nerve in the part moved ; groups of muscles may be 
isolated for the tests. Some few pains are relieved by movement of 
the body, only because the mind is diverted in this act. Pain, when 
superficial and increased by movement, is due to neuritis, myalgia, or 
rheumatism. 

Almost all pains are modified by rest. Its influence has but little 
diagnostic significance. In some cases of doubt as to the nature of a 
visceral pain, functional rest of the organ, by which relief is obtained, 
may aid in determining its locality. Thus, rest to the eye may relieve 
a headache, the nature of which was obscure until this respite was 
secured. Pain modified by temperature (cold or heat applied to the 
spine, ice or hot water in a sponge) and by electricity usually gives 
information as to the seat of the disease in the spinal column, of which 
the pain is the external expression. Pain modified by climate is rheu- 
matic or neuralgic ; if modified by weather or season, it is due to neu- 
ralgia or neuritis, whether of gouty or traumatic origin. 

The patient may describe an excruciating pain in an area, but not 
exhibit outward evidence or physiological change which should accom- 
pany such suffering. Thus the pain may simulate that of peritonitis. 
Such pain is often modified and mollified by fixing the attention of the 



46 GENERAL DIAGNOSIS. 

patient on some other part or on some extraneous subject, when the 
previously alleged tender area may be pressed upon without causing 
any evidence of suffering. Similarly, attention may be called, by a 
leading question, to pain in some other region. The admission of the 
occurrence of such pain, and other evidences of hysteria, point to the 
underlying causal factor in the production of pain. A most important 
characteristic of pain, and one that serves to distinguish the pain of 
organic disease from that of hysterical origin, is its variability with 
excitement, or on fixation of the attention of the sufferer on other 
parts. Moreover, the subject will fall into the trap of describing it as 
having characters contrary to the usual attributes of pain or being asso- 
ciated with phenomena not compatible with the pain — if judicious 
leading questions are put. 

Resume. Notwithstanding clinical investigation we may not be able 
from the character and locality to determine the real cause of the pain. 
In general it may be borne in mind that pains are due (1) to disease of 
the central nervous system or the nerve-trunks ; (2) to inflammations ; 

(3) to intoxications, as from malaria, lead, and other forms of toxaemia ; 

(4) to pressure on the nerve-trunks ; (5) to reflex influences. If in 
doubt, therefore, the general symptoms and condition of the patient 
must be ascertained in order to determine the causal origin, and hence 
the true nature of the pain. In all cases of pain the controlling motive 
in diagnosis should be to determine the general condition of the patient 
and find the cause of the pain. 

Reference must be made to the curious change that takes place in 
persons with chronic morphine intoxication. Such persons are very 
apt to have functional pain. This form of pain is usually paroxysmal 
and severe, and may simulate organic pains. The most common clini- 
cal form seen is gastralgia. The subjects of locomotor ataxia suffer 
from pain, on account of which they have to take enormous doses of 
morphine. This habit is soon acquired, but notwithstanding the large 
dose of the drug paroxysmal pain continues ; in its severity it simulates 
the crises of the primary disease. It becomes a very difficult matter, 
and is often impossible, to decide whether the pain is due to the mor- 
phine-habit or to the primary affection. (See Source of Error, p. 38.) 

Pain in the Head. 

Pains in the head may be classified, according to location, into those 
due to affections of the scalp, those due to affections of the cranium, and 
those due to intracranial conditions. 

1. Affections of the scalp are to be further classified as those of 
the shin, those of the occipito-frontalis muscle, and those of the nerves. 
The occurrence of itching and burning commonly indicates some local 
condition of the skin ; if the itching is slight, seborrhoea should be 
looked for ; if more severe, eczema ; burning and itching of a severe 
type commonly indicate dermatitis venenata ; the pediculus capitis 
should not be forgotten. A feeling of tension, with soreness, accom- 
panies the eruption of erysipelas. Intense local irritations are caused 
by burns and scalds ; the latter, however, are alone likely to give rise to 



THE DATA OBTAINED BY INQUIRY. 47 

error, because the hair is not immediately destroyed. A sore feeling, 
with local tenderness, limited to a sharply denned swelling, with a sen- 
sation of less resistance in the centre and some darkening of the skin, is 
diagnostic of a bruise. Hyperesthesias of the scalp frequently accom- 
pany meningeal and cranial affections, and there are even local changes, 
such as the so-called puffy tumor of necrosis of the inner table of the 
skull. 

Sharp pains in the occipital or frontal region, increased by wrinkling 
the scalp, or brief pressure, but generally relieved by firm and constant 
pressure, occurring with irregular periodicity, and associated with 
meteorological changes, are suggestive of occipital myalgia. The diag- 
nosis is confirmed by the presence of other symptoms of lithsemia. 

Neuralgia occurs in paroxysms, accurately located in the course 
of one or more of the nerve-trunks, and presenting points of special 
sensitiveness where the nerve emerges from the skull and where it 
divides for its cutaneous distribution. The pain is usually relieved 
by firm pressure, but it is to be remembered that sharply local- 
ized pressure on the nerve-trunks against the hard skull will cause a 
traumatic tenderness. The character of the pain is variable ; it may 
be of the most acute or rending form, or, but more rarely, a persistent 
dull ache ; it may be throbbing, or occur in successive paroxysms at 
brief intervals, or it may be regularly periodic. There are often asso- 
ciated vasomotor, secretory, and motor disturbances ; local blushing or 
sweating may be observed along the course of the nerve, and spasms may 
occur in the muscles of the eyelids, for instance, or more general spasms, 
as in the terrible tic douloureux, distinguished by pain from tic convulsif . 
The commonest seat is the supraorbital, the dental, the auricular, and 
the occipital nerves. In the great majority of cases it is unilateral. 

The sensory nerves of the scalp and face are the trigeminus and the 
branches of the cervical plexus. The distribution is as follows : the 
ophthalmic division of the trigeminus is distributed to the eyeball, 
lachrymal gland, the mucous membrane of the nose and eyelids, the 
integument of the nose and upper eyelid, the forehead, and the anterior 
half of the hairy scalp. The superior maxillary division supplies the 
skin over the malar bone, and that of the lower eyelid, side of the nose, 
and upper lip ; the upper teeth, the upper part of the pharynx, the 
antrum of Highmore, and the posterior ethmoidal cells ; the soft palate, 
tonsil, and uvula, and the glandular structures of the roof of the mouth. 
The inferior maxillary division is distributed to the side of the head, 
the upper anterior portion of the external ear, the external auditory 
canal, the lower lip, and lower part of the face ; the tongue, the mouth, 
the lower teeth and gums, the salivary glands, and the articulation of 
the jaw. The great occipital is distributed to the back of the head, the 
small occipital to a narrow region just in front of it, and the greater 
auricular to the skin of the posterior portion of the pinna and the skin 
over the mastoid and parotid gland. 

Pain simulating neuralgia is frequently due to some local irritation ; 
foreign bodies have been known to cause paroxysmal attacks for a 
number of years, until removed ; diseases of the bones are a prolific 
source, especially in the case of the jaws and the cervical vertebrae. 



48 GENERAL DIAGNOSIS. 

Enlarged cervical glands occasionally irritate the great auricular or 
small occipital nerve. Bilateral occipital pain is very characteristic of 
cancer of the cervical vertebrse. In these cases there is usually 
pain on movement of the head or pressure upon it, and some stiffness 
of the neck. Intracranial growths occasionally cause pains, usually 
paroxysmal, limited to one of the branches of the trigeminus. 

Reflex Neuralgia. Certain of the cephalic nerve-pains are symptom- 
atic of disturbance in the associated but distant nervous distribution. 
Pain in the region supplied by the ophthalmic division is very common 
in influenza. It is usually dull, aching, and continuous, increased by 
pressure and anything tending to increase congestion. A severe, acute 
attack of indigestion will produce ocular and supraorbital pain. Re- 
fractive lesions of the eye cause the same kind of pains, which are, 
however, increased by using the eye and relieved by rest and atropine. 
The use of the latter is an important diagnostic procedure. Pain in the 
temporal region and the external auditory meatus is often due to intense 
irritation of some of the branches of the inferior dental ; the usual cause 
is cancer of the tongue, but irritable lingual ulcer may also produce it, 
and even severe inflammatory conditions of the lower jaw. The pain is 
described as sharp, lancinating, and paroxysmal, liable to exacerbations, 
especially when the primary lesion is irritated, and relieved when it is 
alleviated. Pain may be caused in the ear alone when there is irrita- 
tion of the teeth. 

Systemic Neuralgia. Perhaps in the majority of cases of cephalic 
neuralgias the cause is to be found in some systemic disturbance. If 
the attack is preceded by a desire to sleep, occurs when the dew-point is 
high, and is associated with increase of urates in the urine, it is prob- 
ably lithcemic ; the pure gouty forms are most apt to succeed indulgence 
in rich food or red meat, and there is ordinarily irritability of temper. 
Diabetic neuralgias are invariably worse as the amount of sugar excreted 
is increased, and there are usually similar affections of the nerves in 
other parts of the body. Regularly periodic pains, worse in the spring 
and fall, occasionally preceded by a slight chill or malaise, suggest 
chronic malaria. The diagnosis can readily be confirmed by exam- 
ination of the blood and by the detection of enlargement of the spleen. 
Syphilitic neuralgias are usually worse at night ; the pain is described 
as boring, and may be periodical. There is likely to be some thicken- 
ing of the bones, and perhaps a diminution of elasticity of the tissues, 
and almost always local tenderness. The pain is almost immediately 
relieved by iodide of potassium. In anwmic neuralgias the pain is not 
characteristic, but it is temporarily improved by the recumbent posture 
and stimulants, and is worse during menstruation. The general appear- 
ance of the patient and an examination of the blood readily suggest the 
cause. In locomotor ataxia there are occasionally cephalic crises of a 
neuralgic nature ; these come on suddenly and are exceedingly severe, 
but usually occur only at long intervals ; the pain is shooting or stab- 
bing, and does not remain located in one nerve-trunk. Chronic lead- 
and alcohol-poisoning also cause neuralgias, but they are not of them- 
selves characteristic, and never occur as isolated symptoms, being 
frequently associated with peripheral neuritis. 



THE DATA OBTAINED BY INQUIRY. 49 

Secondary Neuralgia. Dull, burning pains, commencing perhaps 
with a chill, and accompanied by febrile symptoms, indicate inflamma- 
tions of the mucous membranes of the head. A dull, persistent head- 
ache located just beneath the eyebrows often accompanies coryza, and 
indicates extension to the frontal sinuses ; if the nose alone is involved, 
there is a feeling of fulness and occasional sharp pains or tickling sen- 
sations. A feeling of dryness and some discomfort on swallowing 
accompanies the various forms of stomatitis and pharyngitis ; in the 
latter there is also a sensation of tickling and fulness in the ear, due to 
extension along the Eustachian tube. Pain at the angle of the jaw, 
with tenderness, and increased on swallowing, almost invariably unilat- 
eral and associated with swelling of the parotid, is unmistakably due to 
parotitis. The neuralgias and inflammations of the middle ear are 
exceedingly painful ; they may consist of a sharp continuous pain, or a 
series of regular exacerbations and remissions, or a throbbing sensation ; 
pain often radiates to the jaws and side of the face. As suppuration 
occurs, the feeling becomes one of extreme tension until the membrane 
is perforated, when there is immediate relief. Tinnitus throughout the 
whole course of the case is very common. The inflammations of the 
eye produce local pain, usually causing the sensation of a rough foreign 
body. Usually there is a slight supraorbital tenderness, and, in iritis, 
sharp pains radiate over the whole area of distribution of the two upper 
branches of the fifth. Certain ulcers of the mouth are comparatively 
painless, noma often developing insidiously. Syphilitic ulcers are to 
be distinguished by their painlessness from simple and tubercular ulcers, 
which are very irritable, and carcinomata, which are liable to paroxysms 
of pain even when not irritated. 

It may not be out of place to mention the value of certain anaesthesias 
as diagnostic signs ; thus in neuritis of branches of the fifth there may 
be cutaneous anaesthesia while there is tenderness over the nerve-trunk. 

2. Affections of the Cranium. A dull, constant headache, limited 
to a small area, later increasing in severity, and the pain assuming, 
perhaps, a boring character ; tenderness, often very severe, over the 
affected area, and probably slight oedema of the scalp, with some 
rigidity of the muscles of the neck, and the ordinary signs of the in- 
flammatory process, indicate inflammation of the cranial hones. In the 
simple cases there will usually be some history of injury, the pains will 
not be especially periodic, and the fever will be irregular. In the 
syphilitic cases there Avill be the history and symptoms of infection, 
the pain will become worse at night, and usually there will be concom- 
itant rise of temperature. The pains will also be controlled by iodide 
of potassium, but as it often requires enormous doses to accomplish 
this result, the failure of a moderate dose should not be considered as 
excluding syphilis. 

3. Intracranial Headaches. Intracranial headaches are functional 
or organic. Both forms may be acute or chronic. The typical acute 
functional headache is seen in the more or less common type known as 
migraine or hemicrania. 

Migraine is a periodical neurosis characterized by pain in the tri- 
geminus and other cranial nerves. The headache is usually unilateral, 

4 



50 GENERAL DIAGNOSIS. 

and, as it is probably clue to vasomotor disturbances, is always associated 
with vasomotor symptoms. It occurs more particularly in women, 
frequently begins in early childhood, and continues throughout adoles- 
cence. It is often hereditary. It occurs most frequently in women 
who suffer from anaemia or from menstrual difficulties. It sometimes 
occurs in the early stages of secondary syphilis. The habit which pre- 
disposes to the headache may develop after long physical or mental 
over-exertion. The attacks, however, are excited by over-exertion, 
mental excitement, or disturbances of digestion. Pain of migraine is 
possibly situated in the pia and dura mater. 

Symptoms. The attack develops with or without premonitions. 
In each individual different prodromal symptoms are recognized as in- 
dicating the approach of an attack. Undue nervousness, a general sense 
of discomfort, pressure or heat in the head, vertigo, tinnitus, spots before 
the eyes, excessive yawning, and repeated chilliness are the most common. 

Premonitory Symptoms. The pain is most frequently felt on the 
left side of the head first. It is seated in the anterior frontal, the 
temporal, or parietal region. The pain is continuous, and increases in 
intensity to the height of a paroxysm. Painful points are not usually 
detected, although the whole skin may be hypersesthetic. The patient 
is sensitive to light and sound, intolerable nausea intervenes, and vomit- 
ing may occur at the height of an attack. The eye-symptoms are very 
pronounced. Flashes before the eyes, scintillating scotoma, or hemian- 
opia may occur. 

The vasomotor .symptoms that attend the attack are of two varieties, 
dividing the disease into the spastic and angioparalytic forms. In 
spastic migraine the skin on the affected side is cool, the forehead and 
ear pale, the temporal artery is contracted, the pupil is dilated, and the 
flaw of saliva increased. In the paralytic form there is redness of the 
face on the affected side. The temporal arteries are dilated and pulsate 
strongly. The face is hot, the pupils contracted, and there is often 
unilateral sweating. 

Chronic Headaches. Chronic functional headaches are usually 
habitual in the sense that the attacks are constant, but there may be 
longer or shorter intervals of freedom from pain. The nerves affected 
are the trigeminus, and the four upper cervical and sensory branches 
of the vagus to the posterior fossa of the skull. Three types of such 
head-pains are seen : ordinary headache, migraine, and neuralgia. 
Headaches are caused, as a rule, by diffuse irritations located in or 
referred to the peripheral ends of the nerve-tracts above referred to. 
Neuralgias, on the other hand, are caused by irritations of the trunks of 
these nerves. 

Causes. 1. Hsemic. (a) Anaemia; (b) diathetic states (gout, rheu- 
matism, diabetes) ; (c) infections (malaria, syphilis, specific fevers). 2. 
Toxic (lead, and other mineral poisons, alcohol, the poison of uraemia, 
tobacco). 3. Neuropathic states (epilepsy, neurasthenia, chorea, hyste- 
ria, neuritis). 4. Keflex causes (ocular, nasopharyngeal, auditory, 
gastric, sexual, uterine). 5. Organic disease. 

Headaches are divided according to their situation into frontal, occip- 
ital, parietal, vertical, diffuse, and combinations of both. The most 



THE DATA OBTAINED BY INQUIRY. 



51 



common forms are the frontal, the frontal-occipital, and the diffuse. 
Ocular headaches are usually frontal when due to errors of refraction. 
When due to muscular insufficiencies they are occipital and cervical. 
Nasopharyngeal headaches are dull, frontal, or diffuse. When the 
pharyngeal tonsil is enlarged the headache may be dull, frequently 
recurring, and seated in the occipital region. In follicular tonsillitis 
and in obstruction of the Eustachian tubes the headaches are diffuse. 
In disease of the middle ear they are temporal and occipital. Gastric 
or dyspeptic headaches without constipation are often occipital, some- 
times frontal. With constipation and intestinal irritation they are diffuse 
and frontal. Uterine and ovarian headaches are occipital and vertical. 
Neuropathic headaches are seated on the top of the head, as in clavus, 
or they are associated with spinal irritation. Neurasthenic headaches 
are usually associated with a sense of pressure or weight, and are seated 
in the frontal and vertical regions. In spinal irritation the pain is of 
a boring character in the occipital region. The earliest symptom of the 
neurasthenic headache is neck-weariness and pain in the neck. The 



Fig. l. 
Anaemia. 
Endometritis. 
Bladder. 



Constipation ; caries of incisor - v 

Error of eye-refraction^ 

Gastric dyspepsia ---w 




^ Eye. 
./—-y Decayed teeth. 
7*-^* Pharyngitis ; otitis media. 



Uterine. 
Spinal irritation. 



Showing the location of pain in various headaches. (After Dana. 



neurasthenic headaches occur in brain-workers when the brain and eyes 
are overtaxed. Headaches in epliepsy are severe, and are confined to 
the vertical or occipital region. 

Organic headaches are usually violent, associated with fulness and 
throbbing. They may be remittent, becoming more intense with each 
exacerbation. The organic headaches may be due to inflammation, to 
abscess and softening, to tumor, to congestion of the brain, and to 
inflammations in the meninges. Anything which increases the blood 
will increase the pain in organic headaches. In acute inflammation 
of the brain the pain is agonizing, continuous, associated with vomit- 
ing and fever, and sometimes delirium. In abscess of the brain the 
pain is less violent. It is occasionally paroxysmal and attended by 
paralysis and disturbed intellection. In tumor of the brain the head- 
ache is severe and paroxysmal. In congestion the pain is dull, increased 
by stooping, by sleep, and by bodily or mental fatigue. Some conges- 
tive headaches are due to violent exercise, and are relieved by bleed- 
ing at the nose. In all congestive headaches the face is flushed, the 
bloodvessels are turgid, and the vessels in the eye-ground will be 



52 GENERAL DIAGNOSIS. 

found to be overfilled. In meningitis the pain is constant, is more or 
less fixed, and sometimes very sharp. Syphilitic headaches are frontal 
or temporal, worse at night, and often periodic. 

Headaches are divided according to the character of the pain : 1. 
Pulsating and throbbing. 2. Dull and heavy. 3. With constriction, 
squeezing, or pressing. 4. Hot and burning. 5. Sharp and boring. 
The headaches of the first class are usually associated with vasomotor 
disturbances, as in migraine. To the second class belong the toxic and 
dyspeptic headaches ; to the third, the neurotic and neurasthenic ; to 
the fourth, rheumatic and ansemic ; to the fifth, hysterical, neurotic, 
and epileptic. Vertigo is a common accompaniment of the dyspeptic 
type of headache situated in the frontal regions. /Somnolence is more 
marked in the syphilitic, ansemic, and malarial headaches. Nausea is 
more common in occipital forms of headache. 

Duration. Eye-strain causes occipital pain, which is rarely per- 
sistent, but comes on after prolonged use of the eyes. It may be asso- 
ciated with headache in other parts, due to other causes. In chronic 
meningitis the headache is persistent and located in the vertex or the 
parietal regions. When thickening of the meninges, with adhesions, 
takes place from trauma, there is constant pain with frequent exacer- 
bations, sensitiveness of the head, incapacity for study. Uremic head- 
ache is not constant. Persistent headache may be present in the latter 
stages of Bright' s disease and in diabetes. In atheroma pain in a part 
or the whole of the head is common. It may be persistent, though 
subject to exacerbations in case of excitement or violent exercise. 
Headache following study, in children, is due to brain-strain, to eye- 
strain, or to indigestion. Persistent headache is sometimes due to 
asthma. In rare instances headache is said to be idiopathic. Neu- 
ralgic headaches are usually periodic, and may be associated with 
throbbings or pulsations. They are associated with vasomotor signs. 
Hysterical headaches are irregular and shifting ; they persist after all 
causes are removed ; they are replaced by pain in other parts of the 
body. They are usually associated with other manifestations of hysteria. 

Neuralgia. 

Neuralgia is characterized by pain in the course of distribution of the 
affected nerve. The pain is of pronounced severity, and occurs in re- 
missions and intermissions. The symptoms of a neuralgic paroxysm 
may be preceded by hyperesthesia over the part subsequently affected. 
The pain is of a burning or shooting character. It is usually limited 
to the distribution of the affected nerve, but may extend into other 
regions. It may be excited by external irritants, by mental excite- 
ment, and often by movement of the part. On examination the area 
of distribution of the affected nerve may be found to be anaesthetic, 
but usually there is a hyperesthesia of the skin. Wherever the 
affected nerve is accessible to pressure pain can be elicited. The nerve- 
trunk may be tender during the attack, as well as during the intervals. 
In neuralgia there is often some spasm of the muscles supplied by the 
nerve. 



THE DA TA OB TAIN ED B Y INQ UIR Y. 53 

Vasomotor symptoms are common. The skin may be pale or red- 
dened. When the trigeminal nerve is affected the skin and conjunc- 
tivae are both reddened. The secretions, as the tears, may be modified. 
Eruptions like urticaria or herpes may develop along the course of the 
nerves. Prolonged neuralgia may cause marked nutritive disturb- 
ances. 

General Conditions. A patient who is subject to neuralgia may 
be in apparent good health. The neuralgia may be due to constitu- 
tional causes, as rheumatism or gout ; to some form of toxaemia, as 
malaria ; to some condition of the blood, as anaemia ; and may be due 
to trauma or to cold. 

The following individual forms of neuralgia are seen : 1. Neuralgia 
of the trigeminus, or tic douloureux. The entire fifth nerve or some 
of its branches are affected. The pain is often severe and may be asso- 
ciated with twitchings, with vasomotor disturbances, with eruptions, 
and with changes in the secretions. Trophic changes, as the hair turn- 
ing gray, or ulceration of the cornea may follow. Usually a single 
branch is affected, either the first branch (ophthalmic), the second 
branch (supramaxillary), or the third branch (inframaxillary). Points 
of pressure are, as a rule, readily detected at the foramina for the exit 
of the nerves. 2. Occipital neuralgia. 3. Neuralgia of the brachial 
plexus. 4. Intercostal neuralgia. 5. Neuralgia of the lumbar plexus, 
of which we have lumbo-abdominal, crural, and obturator neuralgia. 
This form of neuralgia (lumbar plexus) must not be confounded with 
bone and joint disease, with lumbago, renal colic, appendicitis, and uterine 
affections. 6. Sciatica. 7. Genital and rectal neuralgia. 

Trigeminal neuralgia must be distinguished from headache due to 
other causes, affections of the bones and periosteum, and affections of 
the teeth. The distribution and paroxysmal character of the pain and 
the points of tenderness assist in the diagnosis. 

Pain in the Legs and Feet. 

Paroxysmal Pain. Pain in one leg may be due (1) to sciatic 
neuralgia or (2) to neuritis. The former does not exhibit localized 
tenderness and is not aggravated by movement. The latter, also 
called sciatica, is recognized by tenderness in the course of the sciatic 
nerve or at its exit from the pelvis, and by increase in the pain when 
the limb is extended by forced movement. The pain is constant, worse 
at night, and characterized by agonizing paroxysms. It follows ex- 
posure to cold or may be caused by rheumatism. One of the many 
branches of the sciatic may be affected, exhibiting tenderness in its 
course. If the sciatica persists, wasting of the muscles, herpetic erup- 
tions, and areas of anaesthesia over the affected leg may be found. 
Such neuritis is usually traumatic (cold), alcoholic, rheumatic, gouty, 
or syphilitic ; the exact cause in each case must be ascertained by the 
associate phenomena and by the exclusion of other causes. Pain in 
the leg may also be due to (3) pressure on the sciatic nerve by a pelvic 
growth, (4) neuroma, (5) rheumatism, (6) syphilis of bone or a syphilitic 
gumma of muscle or connective tissue. 



54 GENERAL DIAGNOSIS. 

Fixed pain in the leg, in contradistinction to the mobile pains of 
neuritis, is usually situated in the fascice or muscles or in the bones. 
It may be due to rheumatism, when the pain is diffused and the 
nerve points of tenderness are wanting. It may be the result of 
strain or injury, a history of which must be carefully inquired for. 
The latter may be the exciting cause only, in a person of rheumatic 
diathesis, the fixed pain at the situation of the injury being due to 
rheumatism. Fixed traumatic pains are usually accompanied by ten- 
derness on pressure, and aggravated by movement both active and 
passive, the tenderness on pressure not necessarily being in the nerve- 
trunk. In malignant disease of the long bones, mobile neuralgic-like 
pains may precede for some time the fixed pain of the permanent pro- 
cess. (See ' ' A Case of Carcinoma of the Bones," J. H. M.) 

Bilateeal pains in the extremities are often of central origin, and 
may be due to spinal sclerosis ; to malignant disease of the vertebra 
pressing on the cord ; to pelvic growth, or lumbar abscess, causing 
pressure on both nerve-trunks in the pelvis. 

Pains of the feet not due to affections of the large nerve-trunks are : 

1. Pain in the Articulations due to Flat-eoot. This may 
be in the tarsus or at the metatarsal articulations. It is a common 
cause of pain in the extremities, and may be unilateral or bilateral. 
Flat-foot from breaking of the arch can readily be recognized ; pressure 
on the sole of the foot may increase the pain. 

2. Pain in the Heel. This is often of gouty origin, and is a per- 
sistent source of complaint in many instances. 

3. Pain in the Interosseous Spaces Between Distal Ends 
of the Third and Fourth Metatarsal Bones (Morton's painful 
affection of the foot). It occurs in people who are on their feet a great 
deal, is relieved by a night's rest, increases as the day goes on, and is 
increased by pressure or by wearing a tight shoe. It is worse in wet 
and cold weather. Localized pressure at the point on the sole indicated 
above causes extreme pain. 

We cannot leave the extremities without a word regarding pains in 
the extremities of distinctly central origin — the forerunners of hemor- 
rhage into the brain. Mitchell has called attention to these pains. 
They occur suddenly without evidence of local disease ; they are 
located in one of the extremities, usually the leg, are excruciating, 
and not influenced by position, local applications, or pressure. In 
a patient with hard arteries and high pulse-tension they should be 
looked upon with suspicion. 

Pain in the Arms. 

Unilateral Pain. It may be due (1) to neuritis associated with 
tenderness of the nerve-trunk ; (2) to neuroma, as, indeed, any peripheral 
nerve may be affected ; (3) to simple neuralgia or neuralgia from the 
pressure of enlarged axillary lymphatic glands ; of a morbid growth 
of an aneurism on the nerves ; (4) to rheumatism or myalgia ; (5) to 
bone disease. 

Bilateral pain in the arms is of central origin, due to diseases of the 



THE DA TA OB TAIN ED B Y INQ UIB Y. 55 

vertebra or of the spinal cord, or neuralgic, due to anaemia or toxaemia 
of some form. 

Pains of the Thorax. 

Painful diseases of the muscles and of the viscera will be considered 
in the chapters on Diseases of the Heart and Lungs. Pains of reflex 
origin will be referred to. They are usually seated in the shoulder or 
the back, and are due to liver or gastric disease. The pain of liver 
disease is referred to the right shoulder ; of ulcer of the stomach, to 
the interscapular region and the lumbar region, or to the top of the 
shoulder, as in a case observed by Wood. 

Pain behind the sternum is often a reflex neurosis from gastric dis- 
order. It may occur in bronchitis. It may also be due to cancer of 
the mediastinum, to aneurism, or angina. Pain in the sternum or ribs 
is syphilitic or due to periostitis or necrosis following typhoid fever, 
rarely to cancer. Chronic fibrous inflammation of one or more of the 
attachments of the muscles is of common occurrence. The pain lasts 
for years. It is persistent, sometimes associated with stiffness ; it is 
increased by movement, and there may be extreme aching pains in the 
parts. The pain of vertebral caries transmitted along the course of 
the nerve has been referred to. 

Girdle-pain. This is a peculiar pain or sensation in the trunk, due 
to disease of the spinal cord. It is described as the sensation of a band 
drawn tightly around the body. It varies from a simple drawing 
sensation to extreme pain which encircles the trunk. It is situated 
above the level of the umbilicus. In milder forms it is due to chronic 
myelitis or spinal sclerosis ; in severe forms to inflammation of the 
nerve-roots, or to cancerous, syphilitic, or tubercular disease of the 
meninges. 

Pain in the Spine. 

Pain in the spine is due less frequently to organic disease of the cord 
than to acute or chronic inflammation of the meninges, to disease of the 
bones of the vertebral column, or to curvature of various forms from 
muscle- weakness. Rhachialgia and tenderness in the course of the 
spine occur after concussion. 

I. Disease of the Spinal Cord. In organic disease of the 
cord pain may be referred to the loins, the sacrum, or to the parts about 
the spine, but not to the spinal column itself. In the same disease of 
the cord we may have also the eccentric or radiating pains, of which 
mention has been previously made, due to irritation of posterior nerve- 
roots. They may be dull, resembling those of rheumatism. In acute 
cases the pains are accompanied by febrile symptoms, which may simu- 
late rheumatism, especially when the other spinal symptoms are in 
abeyance. In chronic cases these peripheral spinal pains are influenced 
by the weather, and this likewise makes it difficult to distinguish them 
from rheumatism. Rheumatic pains in the limbs occurring after middle 
life, with or without joint-changes, should suggest locomotor ataxia. 



56 GENERAL DIAGNOSIS. 

In this affection sharp and darting pains, " pain crises/' and girdle 
sensations occur. 

II. Disease of Vertebrae. Fixed localized pain at some point 
in the vertebrae points to traumatic, syphilitic, or tubercular caries, or 
to pressure necrosis, as by an aneurism. Pain due to vertebral dis- 
ease is both local and radiating. It is increased by pressure directly 
on the spinal column (on the head), by heat or by cold, or by electricity, 
applied over the part. It is relieved by removing the pressure of the 
weight above, as by raising the head or shoulders. It is relieved by 
the absolutely recumbent posture. With this pain the movements 
(flexibility) of the spine are interfered with, because of spasm of the 
muscles or anchylosis ; there may be deformity. When the patient is 
placed upon a flat surface the normal lumbar arch is changed. 

, III. Disease of Meninges. Pain due to meningeal disease is local 
and radiating. It is associated with muscular spasm and stiffness of 
the spinal column. 

IV. Spinal Curvature. The pain of curvature from muscular 
weakness extends along the nerves. The patient is afebrile. The signs 
of organic disease above mentioned are absent, but muscle-weakness and 
general signs of debility are present. Pain in the spine frequently attends 
scurvy and rhachitis. It may be accompanied by paresis of the muscles 
and closely simulate an organic brain or cord disease. 

Pain in the Side. 

Pain in the left side — the so-called inframammary pain — is one of 
the most frequent complaints heard by the practitioner. By discussion 
of it we can show how the symptom pain, wherever situated, must be 
investigated in order to determine the tissue affected and the nature of 
the disease. The tests used in the study of nerve affections (q. v.) are 
not given. It may be due to many causes, to exclude any one of which 
inquiry as to the mode of onset, duration, and character of the pain 
must be made. Then the structures underneath and about the seat of 
pain must be examined. 1. The skin : to exclude any swelling or 
tumor or herpes zoster, and to determine the tender nerve-points. 2. 
The muscle : to exclude myalgia or pleurodynia. Examine for tender- 
ness ; note the effect of movement ; does full breathing increase the 
pain ? Palpate Avith the fingers and with the whole hand. Negative 
results exclude any muscular affection. 3. The nerves, (a) Tender 
points ; (b) herpes ; (c) the vasomotor appearance. The presence of 
anaemia, other neuroses and neurasthenic phenomena, or toxic condi- 
tions, as malaria, lead, or gout, lend color to the view that the pain is 
neuralgic. 4. The pleura. Auscultate for friction if pleuritis. In- 
quire for cough. Note the character and effect of breathing. 5. The 
pericardium. Note friction of pericarditis or thrill by palpation. Is 
the heart disturbed in function ? 6. The heart. It is rare that disease 
of this organ causes pain, although it maybe present in dilatation. Is it 
affected in a reflex manner, causing palpitation or irregularity ? Look 
for distant disease. Angina or pseudo-angina pectoris may be present 



THE DA TA OB TAIN ED B Y INQ UIR Y. 57 

7. 1 The stomach and colon. A dilated stomach or loaded colon may 
cause pain by pressure upward. Gastralgia may also be the cause. 8. 
The spine. Determine if it is diseased or if there is pressure by an 
aneurism or a mediastinal growth. If a local cause is not ascertained, 
look for a central or reflex disorder. 

Although any one of the above conditions may cause pain in the 
side, it is usually (1) a reflex pain from gastric disorder; (2) pain from 
neuritis ; (3) a true neuralgia from anaemia ; (4) a neuralgia from heart- 
fatigue. (Hilton.) 

It is to be observed that every local tissue must be examined, and 
questions asked as to the various attributes of the pain. 

Pain in the Loins. 

When acute, without fever, pain in the loins may be due to lum- 
bago, to a sudden uterine retroversion, to a suddenly moved kidney, or 
to calculus of the kidney ; with fever, acute Bright' s disease, smallpox, 
muscular rheumatism, tonsillitis, influenza, dengue, or spinal meningitis 
must be looked for. 

Chronic Pain in the Back ; Backache. Backache may be due to 
many causes. When in the region of the kidneys, they may be at 
fault. Organic disease (Bright's) may be associated with backache ; 
more frequently, pain, if in one kidney, is due to a calculus or to accu- 
mulation of uric-acid gravel. Pressure over the kidney or a sudden 
jar from a false step will usually excite the pain. It may be constant 
in moved or movable kidney. When low down, just above or over 
the sacrum, it is due to disturbance of the pelvic viscera. The uterus, 
the colon, and rectum (impacted, cancerous) must be examined 

Otherwise we may have — (a) Pain due to affections of the muscles. 
1. Myalgia of rheumatic origin. Increased by movement, by damp- 
ness, by pressure. Often relieved by warmth, by the recumbent 
posture, or rest. It is associated with symptoms of lithsemia and with 
the passage of red sand in the urine. When the fascia or the ligaments 
of the vertebrae are affected, the upright position and pressure in small 
areas increase the pain ; other muscles may be affected alternately. 2. 
Myalgia from sprain. A history of injury is obtained. Usually one side 
is larger than the other. Tenderness is present and movement in- 
creases the pain. There may be increased swelling, vasomotor disturb- 
ance, or ecchymoses. A neurosis of the so-called spinal or traumatic 

1 Shoulder-tip pain, due to anastomosis of phrenic nerve with 3d and 4th cervical 
and to parts of liver and round ligament i Hilton) ; or of phrenic nerve and subclavius 
(Rolleston) ; or of vagus with spinal accessory, which communicates with 3d and 4th 
cervical. The v. and s. a. are sensitive to pressure. (Embleton. ) 

Inframammary pain (6th, 7th, and 8th intercostal spaces). The aorta at left side, 
3d dorsal vertebra, is in relation with the 4th, 5th, and 6th intercostal nerves through 
the sympathetic ganglia, through which also the heart sympathetics are in anasto- 
mosis The 4th, 5th, and 6th intercostal nerves supply cutaneous branches to the 
6th, 7th, and 8th intercostal spaces. The inframammary pain is a reflex neuralgia 
expressive of some heart-distress. The latter is brought about by exhaustion of the 
medullary and vasomotor centres, from worry or overwork, or from long-continued 
irritation of the uterine nerves. In leucorrhoea this pain is most common. (Jacob- 
son : Hilton on "Eest and Pain.") 



58 GENERAL DIAGNOSIS. 

type (hysteria) attends the pain. 3. Myalgia from fatigue. Not only 
acute fatigue after exertion, but chronic muscle-tire (and nerve-tire). 
The pain is increased on exertion, after mental, physical, or emotional 
effort. Neurasthenia, anwmia, or local exhaustive disease (uterine, 
gastro-intestinal, etc.) are present. The muscles are usually flabby, 
and the vertebral column is not supported. The patient lounges or 
supports the back. Spinal curvatures are observed. 

(6) Pain due to affections of the nerves. Nerve-pain is recognized 
by the tender points ; by vasomotor phenomena. 

(c) Pain due to disease of the spine, the membranes, or the cord. 
(See above.) 



CHAPTER Y. 

THE DATA OBTAINED BY OBSEEVATION. 

The objective symptoms correspond to phenomena in nature. Method of procedure; 
method of the observer. Inspection, palpation, percussion. The instruments 
required. 

The Objective Symptoms. 

The objective symptoms of disease are the most important to ascer- 
tain. They are the " handwriting on the wall." The impress of 
forces for good or evil is observed. In determining them we deter- 
mine the physical, chemical, and vital condition of the organism ; its 
state after the action of the forces of its environment. The physical 
and mental status of the patient is measured. He is individualized. 
The objective symptoms are data by which a complete diagnosis is 
made. Without such data the diagnosis is mere guesswork — one of 
probability. With such data alone, if accurately and precisely col- 
lected, a positive diagnosis can very frequently be made. A correct 
diagnosis depends upon the skill and thoroughness of the physician and 
his ability to interpret the data secured, always provided that clear, 
succinct data can be obtained 

The data obtained by inquiry are carefully recorded, after which the 
following procedure is conducted. A physical examination of the 
patient is made, followed by an immediate study, or, if time permits, a 
study at leisure of the fluids of the body — microscopically, chemically, 
and bacteriologically. In the physical examination we make a general 
survey of the individual, and form an estimate of his height and weight. 
The various organs and tissues are interrogated by the senses appli- 
cable to the investigation of each, aided by special instruments. The 
natural secretions and discharges, abnormal discharges, all exudations 
or transudations, and cystic fluids are passed upon. 

The student will soon learn that the process of ascertaining the ob- 
jective signs of disease is in no respect different from that which obtains 
in the study of any object in nature or any like phenomena. The 
chemist notices the form, the color, the density, etc., of the object 
under examination ; the effects of heat and cold, of various reagents 
upon its structure ; he determines its component parts and ascertains 
its relation to other objects in nature. From data thus obtained by 
the use of all his senses he classifies the object. The biologist notes 
not only the physical appearance of a given form of life, but also the 
phenomena of the living, sentient matter under all conditions in a 
varied environment. By comparison and analysis the living being is 
classified. 



60 GENERAL DIAGNOSIS. 

By the same powers of observation and the same analytical process, 
the departures from health are recognized and classified. Is it not, 
therefore, a wonderful aid to the diagnostician to possess faculties 
which have been trained to minute observation by previous studies in 
sciences allied to medicine ? 

What has been thus imperfectly said is intended to emphasize the 
fact that no mystery attends the recognition of the objective signs of 
disease. Abundant opportunities of observing disease at the bedside, 
patient training, skill in technique, and a systematic procedure are 
essential. 

Method of Procedure. 

The method by which the data ascertained by observation are secured 
is modified by the circumstances under which the patient is seen. It 
is obvious that the patient who comes to the office, or is not sufficiently 
ill to be in bed, has sufficient strength to stand, and should be given 
an exhaustive examination. Moreover, we can inquire into certain 
abnormalities, as the gait, not visible in bed. On the other hand, in 
the case of a bed patient, we learn the position he assumes when lying 
down, and have better opportunities for thorough examination of the 
various organs. Often the objective examination must be very brief, 
on account of the patient's extreme illness. It may be advisable, 
although unfortunate, to exclude one or more methods, as percussion, 
if there is pain, or auscultation, if there is great restlessness or orthopnoea. 

If a complete examination is made, it is well to begin with the 
exterior. After the external examination is made, the internal exami- 
nation is conducted, by grouping together and examining organs func- 
tionally related, as the heart and bloodvessels, in diseases of the heart ; 
the nose, larynx, and lungs, in diseases of the latter. The student will 
do well to begin at the head and take up the organs in their continuity. 

Comparison. The results obtained by observation are based upon 
comparison ; the student must bear this constantly in mind. We 
compare the body as a whole with our conception of the normal indi- 
vidual, formed by a study of a large number of persons. We compare 
symmetrical parts — the right side of the chest with the left, the arm 
suspected to be the seat of the disease with the healthy arm, etc. The 
cardinal rule in an examination is to base the significance of ascertained 
facts upon comparison with known normal conditions. 

Methods of Observation. 

Securing the Data. To accomplish these ends, examination is 
made by the sense of sight (inspection) ; by the sense of touch (palpa- 
tion) ; by the sense of hearing (auscultation) ; and by the sense of hear- 
ing applied to the discrimination of sounds developed by percussion. 
By percussion or tapping the part we also elicit the peculiar phenom- 
ena known as reflexes. 

The sense of taste is not used to determine the objective phenomena 
of disease. Some data, such as the odor of the exhalations and dis- 
charges, are obtained by the sense of smell. 



THE DATA OBTAINED BY OBSERVATION. 61 

Inspection. By inspection we judge of the physical condition of 
the whole or a part of the body, as seen in the shape and size and in 
the color ; of the vital condition, by the expression of countenance, by 
the character of the movements of the body as a whole or in part, by 
the position in bed, and by the gait. The appearance of fluids (blood) 
and of discharges is also observed. The results of inspection as to size 
are confirmed by actual weighing. 

In order that the data obtained by inspection may be complete and 
accurate, every portion of the body, and of its internal cavities which 
can be seen by the unaided or aided eye, should be inspected. The 
clothing should be removed, and, bearing in mind the proprieties, the 
whole body should be examined. For this purpose the patient should 
be under a good light. The light should always fall directly on the 
surface. The entire surface, of course, need not be exposed at once, 
and circumstances may be such that only one portion need be exam- 
ined. Nevertheless, the fact must be insisted upon that patients who 
have been ill for a considerable time, as well as all grave cases, should 
be examined all over. It is even more important to do this if the 
patient is comatose. A node on the tibia, undue prominence of the 
vertebrae, a special rash about the anus, may afford information which 
could not be obtained in any other way. It is assumed that the patient 
has been examined lying down. In nervous diseases and diseases 
affecting the muscles and bones, the patient's gait, his ability to stand, 
the method of rising or assuming a sitting posture, and the performance 
of other customary physiological acts should be observed. For this 
purpose, as above mentioned, portions of the body can be covered, or a 
light gown thrown over the patient from head to foot. 

Method of the Observer. In order to secure the data in full, 
the student should teach himself a method of observation by which all 
the facts are collated in regular systematic order. Whether the exam- 
ination is general or local, whether the whole of the body is referred to 
or only a part, as, for instance, the nose, the student should accustom 
himself to make observations in the following order : First, the shape 
or contour (expression) ; second, the size ; third, the color ; fourth, the 
movability and the physiological condition of the part on movement. 
If this plan is pursued, little, if anything, will be overlooked. A simi- 
lar order should be followed in the investigation of the character of the 
secretions and excretions of the body. 

Inspection of Special Regions. In the inspection of special 
regions artificial light and special instruments are also required. The 
artificial light should be secured from an Argancl or Welsbach burner, 
or from a gas-jet with a reflector, or from electricity. To facilitate the 
examination the room should be darkened and head-mirrors used as 
reflectors. A number of these have been devised, any one of which is 
suitable if it fits the head well and can be adjusted with comfort, so that 
the observer can throw the light on the part he wishes to examine, and, 
at the same time, peer through the centre of the mirror. A special 
arrangement of the patient and the light is required. The patient 
should sit in an easy, comfortable, erect position, with the light on a 
level with the part to be examined, a little behind, and to his right or 



62 GENERAL DIAGNOSIS. 

left, according to the convenience of the examiner. Special apparatus 
is required for the examination of each cavity : mirror, tongue- 
depressor, and specula for the throat, an ophthalmoscope for the eye, 
etc. (See respective sections.) 

Palpation. The results of inspection are confirmed, when possible, 
by palpation, and the sense of touch supplies additional data. The 
nutrition of the parts is ascertained. The density, the resistance, the 
special character of the part, whether solid or liquid, are determined by 
this method of examination. On examination of the skin, the degree 
of dryness or moisture, the character of the skin, whether smooth or 
rough, the density of the part — as to degree of thickness and resist- 
ance — are all ascertained by means of the sense of touch. The pres- 
ence or absence of pitting is observed, and the nature of swellings 
ascertained. In a similar manner local areas are examined. The 
same routine method should become habitual with the student. First, 
the shape and contour ; second, the size ; third, the color, its change 
on pressure, etc. ; fourth, the movability of the part, and the character 
of the normal movements, as when a joint is under observation ; fifth, 
the resistance and density of the part examined, or special characteris- 
tics revealed by touch — the elasticity of the skin, firmness of muscles, 
and, in swellings, the presence or absence of fluctuation. Other phe- 
nomena are detected, which are vital, in contrast to the above, which 
are physical. By palpation, alone or with instruments, we determine 
the sensibility of the part, the presence or absence of tenderness, the 
temperature, and the degree of moisture. In the examination of special 
regions by means of palpation some phenomena are determined pecu- 
liar to the system under examination, and dependent upon its physio- 
logical or functional action. Thus, in palpation of the chest, in addi- 
tion to its movement, we note the vibrations transmitted to the hand 
when the patient is asked to speak, or detect abnormal vibrations from 
the friction of two rough surfaces together (pleura), or from the throw- 
ing of fluids into agitation : fremitus, friction, and rales are thus trans- 
mitted. 

Knowledge of the action of the heart and of its position is obtained 
by palpation ; thrills are detected, abnormal impulses felt. (For 
method of procedure, see respective organs.) 

Auscultation. By auscultation we hear and analyze the sounds 
that attend respiration, the movements of the heart and of the blood in 
the bloodvessels. Abnormal sounds may be created in the pleura and 
pericardium — and in hollow viscera, as the oesophagus, stomach, and 
intestines — and their presence is likewise ascertained by auscultation. 
(See Diseases of the Lungs and Heart.) The character of the voice as 
to the quality and degree of loudness is studied to determine abnormal- 
ities in the respiratory tract or any speech defects of central or periph- 
eral origin. 

Percussion. By percussion, sounds are elicited which indicate the 
physical condition of the part percussed. In health the lungs and the 



THE DATA OBTAINED BY OBSERVATION. 63 

gastrointestinal tract contain air in certain proportions, and therefore 
the sounds yielded by percussion are always of a known character. 
Any change from the normal sound is indicative of disease, of abnor- 
mal structure, or of alterations in the normal relations of the parts. 
Percussion determines these changes, and, in addition, enables us to 
estimate the size of organs. It is possible to determine the size of the 
liver, the heart, or the spleen, because of the relationship of these 
airless, non-resonant bodies to the air-containing structures around 
them. As this method of securing data is of the greatest use in pul- 
monary and abdominal diseases, the mode of procedure will be described 
in the chapters on Diseases of the Lungs and Abdomen. 

Other Methods to Secure Data. In addition to the data obtained 
by the above methods, valuable and essential data are obtained by 
chemical, microscopical, and bacteriological examinations of the fluids, 
discharges, exudations, and transudations, and by aspiration and special 
examination of the fluids obtained from the natural cavities, or from 
cysts of the body. Bacteriological diagnosis and exploratory puncture 
will be considered in a special chapter. 



CHAPTER VI. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 

The first sight impressions. General abnormal vital conditions. Fits or seizures. 
Coma. Collapse. Shock. 1. The personal appearance. 2. The apparent age. 
3. The temperament and constitution. 4. The attitude and gait. 5. The general 
form and nutrition. The size— enlargement, diminution. The weight. 

GENERAL EXAMINATION OF THE EXTERIOR. 

The general appearance of the patient affords an idea of the ability 
he has to cope with the antagonistic forces of his environment, or to 
overcome the deleterious effects of his occupation. It indicates the 
effect of present or past disease or of inherited disease. The first sight, 
striking impression, is always to be noted. " Very sick," " coma- 
tose," " collapsed," etc., or " robust," " cyanosed," etc., are speaking 
memoranda. To the experienced practitioner, the opinion formed at 
first glance is often of great diagnostic significance. It may happen 
that the patient is suffering from some unusually abnormal vital con- 
dition, a study of which must be made before the exhaustive survey of 
the case Ave are about to enter upon is conducted. 

General Abnormal Vital Conditions. Impairment of conscious- 
ness and fits are readily recognized. The two often go hand-in-hand, 
but in some instances, as in fainting-fits, consciousness is not lost. 
The following list includes the various forms with their associate phe- 
nomena. Only those are mentioned which occur instantaneously. For 
their symptomatology and diagnosis the appropriate sections on special 
diagnosis must be consulted. 

1. Unconsciousness, a. Syncope. The face is pale but calm, the 
pulse feeble or imperceptible, the extremities cool ; nausea or hurried 
breathing may precede. The breathing is quiet in the attack. The 
pupils respond to light. No pain. (See Heart Disease.) 

b. Cerebral Disease. (Spasm is sometimes associated.) Head- 
pain, congested face, hemiplegia, facial palsies, pupils irregular and 
irresponsive, cornea not sensitive; incontinence of urine. 

c. Intoxications. Alcohol, opium, and other narcotics ; ursemia, 
diabetes, toxaemia from infections, sunstroke. 

2. Fits. a. Epilepsy. (1) "Hautmal:" aura, convulsions ; (a) 
tonic, respiratory muscles affected, face livid, stupor afterward ; (6) 
clonic, tongue bitten, stupor follows. (2) ' ( Petit mal :" pallor sudden, 
no convulsions. 

6. Infantile Convulsions. Usually reflex from indigestion ; 
may be the onset of a specific fever or due to high temperature. 



THE DA TA OB TA IN ED B Y OBSER VA TION. 6 5 

c. Puerperal Convulsions. Headache, amaurosis, oedema, sup- 
pressed and albuminous urine ; clonic convulsions, tongue bitten, com- 
plete coma. (See Uraemia.) 

d. Uraemia. Unilateral or bilateral clonic convulsions. (See Renal 
Disease.) 

e. Alcoholism and Sunstroke. 

/. Organic Brain Diseases (syphilis, tumor, softening, etc.). 

g. Fits with Partial or no Loss of Consciousness. Hystero- 
epilepsy, focal or Jacksonian epilepsy, hysteria, cerebral embolism, 
thrombosis, or hemorrhage, spasms of various kinds. 

h. Fits with Vertiginous Movement. The forms of vertigo are 
gastric, aural, and labyrinthine (Meniere's, also paroxysmal), ocular, 
cerebellar, from congestion of the brain (reflex), epileptic. 

3. Collapse. Collapse may occur in a person in apparent health 
and be the first indication of disease, as in rupture of a large blood- 
vessel causing internal hemorrhage. Or it may occur in the course of 
disease, as typhoid fever, when intestinal hemorrhage takes place. 

The symptoms are those of prostration, with partial loss of con- 
sciousness, or the mind is perfectly clear. The face is pale, pinched, 
and bathed with perspiration. (See Hippocratic Facies.) The skin is 
cool and clammy. The hands are cold. The skin is wrinkled. The 
eyes are sunken and encircled by dark rings. The voice is weak or sup- 
pressed. The pulse is rapid and thready, or may be absent at the 
wrists. The heart-sounds are indistinct. The temperature falls. The 
respiration may be hurried or shallow, sighing and gasping. The 
urine is scanty or may be absent. Collapse is due to hemorrhage, ex- 
ternal or internal ; to perforation of abdominal viscera ; to peritonitis ; 
to excessive watery discharge, as in cholera or serous purging. It may 
be due to pernicious malarial fever. Coma attends this form. 

4. Shock is a condition in which the vital powers are blunted or 
stunned, with or without mental terror or anxiety. It is likely to be 
seen in injury, surgical operation, hemorrhage, angina pectoris, severe 
pain from any cause, any sudden cerebral or spinal lesion, undue 
mental and emotional strain. Its presence points to a grave ante- 
cedent condition, near or remote. The symptoms are those of collapse. 

Location of Disease. A general view of the exterior will often 
indicate which system is the probable seat of the disease. For instance, 
violent respiratory action points to the lungs ; paralysis, to the nervous 
system ; the enlarged abdomen, to disease of the viscera in that region. 
The apparently hasty view has already given the practitioner much 
information. 

We then note with more deliberation (1) the personal appearance ; 
(2) the apparent age ; (3) the temperament and constitution of the 
patient or the evidence of any diathesis or cachexia ; (4) the position 
assumed in standing, walking, or in bed ; (5) the general form and 
nutrition. 

1. The Personal Appearance. 

From the general appearance, the patient's habits as to industry, 
neatness, or care of dress may be observed ; these habits are of diag- 

5 



QQ GENERAL DIAGNOSIS. 

nostic importance, particularly in brain affections. The appearance 
also shows frequently whether the patient is addicted to alcohol or to 
the use of narcotics. Moreover, the slit-boot, to relieve the swelling of 
gout, the loosely fastened boots from swollen ankles, the unduly worn 
sole as in spastic paralysis, the unbuttoned waist-band because of dropsy 
or increased weight, the stained trousers from drops of urine, are seem- 
ing trifles, but of diagnostic value. 

The occupation of the patient is often important in throwing light 
upon his disease ; the brown, weather-beaten face of the farm laborer, 
sailor, or driver contrasts strongly with that of the merchant, clergy- 
man, or clerk. A machinist can often be recognized by his grimy, oily 
hands. All this information can be obtained at a glance, and many 
details can be added before the patient has taken his seat in the con- 
sulting-room. 

2. The Apparent Age. 

The apparent age of the patient should be estimated from his appear- 
ance, and compared with the exact age when this is learned later. In 
this way the physician will be able to judge whether the patient is 
aging too rapidly or bearing his age well. An obvious advantage of 
noting the patient's age is that it enables us at once to exclude a large 
number of diseases which are not found in the period of life to which 
the patient belongs. For example, if the patient is a child, we need 
not consider the chronic degenerations and the visceral cirrhoses which 
appear in middle and later life. Conversely, in an old person we do 
not expect to meet with the exanthemata which affect children almost 
exclusively. So, too, typhoid fever and pulmonary tuberculosis are 
more common in adolescence and early manhood than in childhood and 
old age. Again, in very young girls, the question of menstruation and 
its difficulties never have to be considered. Gray hair in a person 
under thirty-five generally indicates a feeble constitution and prema- 
ture age. Loss of hair is not significant, for, apart from a tendency to 
baldness which is very marked in some families, professional men who 
do much brain-work, especially in hot, close rooms, are apt to become 
bald much sooner than other men. The presence of wrinkles at the 
corners of the eyes and of " crow's feet/' and of dull, dry, lustreless 
eyebrows, should be noted as indicating aging, whether the person has 
lived long or not. In women approaching forty, who do not gain in 
flesh, there is often a suggestive prominence of the angles of the jaw 
and sternomastoid muscles, with a certain loss of roundness and elas- 
ticity of the cheeks. The latter appearance, however, may be due to 
loss of molar teeth. 

3. The Temperament and Constitution of the Patient. 

In former times emphasis was laid upon appearances which pointed 
to a particular diathesis or type of inherited constitution. Five varie- 
ties of diathesis were described to which general appearances pointed. 
They were the gouty or sanguine-arthritic, the strumous, the nervous, 
the bilious, and the lymphatic. While certain appearances point to the 



THE DATA OBTAINED BY OBSERVATION. 67 

occurrence of groups of individuals who may be classified under one of 
these diatheses, it is well not to lay too much stress upon them for 
diagnostic purposes. As pointed out by Gairdner, it is not proper to 
designate the diathesis off-hand. Individual appearances should be 
carefully noted, so that only after the completed examination a final 
conclusion as to the diathesis can be drawn. 

In the gouty or sanguine diathesis the osseous system and muscles 
are well developed, the nutrition active, and the patient usually robust 
in appearance. The digestion is good, respirations deep, the circula- 
tion is well carried on (as shown by the florid skin and the large heart), 
the pulse is firm and steady, and the pressure in the arteries is high. 
The head is large and the jaw prominent, the teeth good. The hair is 
of strong growth. The individual with such diathesis is predisposed 
to the arterial changes of advancing age. Apoplexy, aneurism, and 
angina pectoris, or complications resulting from the senile changes in 
the heart and arteries, develop. 

In the strumous diathesis the bones and the glandular system are 
changed and the appearance of the face is expressive ; the bones of 
the chest are small ; the long bones are slender, while their epiphyses 
are large ; the forehead is broad and prominent, the lips full, the alee 
nasi thick, the teeth are carious, the lower jaw light and thin, the hair 
is fine and often of a light hue, the eyelashes long, the eyebrows arched, 
often heavy. In this diathesis the nutritive changes are poor, inflam- 
mations are usually sluggish ; disease of the bones, of the glands, and 
forms of tuberculosis are apt to be more severe. 

In the nervous diathesis we see small, active, restless beings, with 
small bones and large muscles. They are full of energy, and carry on 
large business or mental operations. The features are well formed, the 
eyes active. Such types readily become the victims of overwork and of 
early breaking-down of the nervous system and of dyspepsia. They 
possess idiosyncrasies toward drugs, particularly opiates. 

In persons of the bilious diathesis we find a dark skin, dark hair, 
muddy conjunctivae. They are usually not well nourished. Their 
digestion is poor, and they are subject to attacks of so-called bilious- 
ness. Sick headaches are common. Fatigue is not borne well. 

In the lymphatic diathesis there is lack of energy and sluggishness of 
nutritive processes ; such persons are unable to keep up in the wear 
and tear of life. They are usually pallid and have soft muscles. 

In addition to diathesis, cachexice are also noted. Cachexias arise 
from the ravages of disease, especially when the number of the red 
cells of the blood is reduced and the haemoglobin diminished. Cachexia? 
are caused especially by syphilis, gout, and chronic malarial poisoning. 
In cancer of some part of the digestive apparatus — and, indeed, in all 
forms of chronic disease of the digestive tract — a cachexia is seen. 
The anaemia from poisoning with lead, arsenic, and other metallic 
poisons produces an appearance to which the term cachexia has been 
applied, although in truth it only resembles one. Each form of 
cachexia takes its name from its cause, as the syphilitic or the cancer- 
ous cachexia. 



GENERAL DIAGNOSIS. 



4. The Attitude and Gait of the Patient. 

The attitude of the patient gives information as to his physical vigor, 
and, to a certain extent, of his alertness of mind. A man vigorous of 
mind and body will stand firmly upon both feet, with back straight, 
shoulders square, and head erect. When one is depressed by care or 
disease the shoulders have a tendency to droop and the head to fall 
forward. Indecision and a vacillating disposition are sometimes indi- 
cated by the patient standing first on one foot and then upon the other 
while talking, or by an unsteady look from the eye. 

When one shoulder is lower than the other and the patient is of 
phthisical build, pale, and emaciated, the attitude is strongly suggestive 
of phthisis or chronic pleurisy on the side on which the shoulder is 
depressed. Sometimes, in acute pleurisy, the patient will walk with 
the shoulder depressed and the arm firmly pressed against the affected 
side, so as to restrict its movements as much as possible. 

Decubitus. The attitude of the patient in bed is often significant. 
He may assume the active dorsal, or the side position, with the body 
arranged so that it is comfortable and unconstrained. Then slight in- 
disposition only is present. On the other hand, the side position, the 
dorsal position, or the upright or semi-upright position may be assumed. 

To the close observer the attitude of a patient in bed is sometimes 
reassuring. He lies easily upon his back, or turned slightly to one 
side with the arms uncovered, and may even turn or sit up to meet 
the physician as he enters the room — all these signs point to moderate 
illness or to the approach of convalescence. 

Side Position. A patient with acute pleurisy or pneumonia will 
lie on the affected side so as to limit its motion as much as possible. 
The breathing will be shallow and frequent, the expression of the face 
anxious, and occasionally a spasm of pain contracts it as the patient 
coughs or is obliged to take a full breath. He usually lies on the 
affected side because fixation is thus secured and pain on inspiration is 
diminished, and also because there is a greater liberty for expansion of 
the free, healthy side. If effusions are present, by lying on the side of 
the effusion pressure is removed from the heart and the unaffected 
lung, an obvious advantage. 

At times, in case of thoracic aneurism, if situated on one side, or of 
movable thoracic tumors, the patient will lie on the side which is the 
seat of the disease. 

The dorsal position, as assumed in health or slight disease, has 
been referred to. When the position is assumed in grave disease it is 
called passive dorsal, because it is often assumed without volition of 
the patient. 

In grave cases of typhoid or other low fevers the patient lies upon 
the back and shows a marked tendency to slip down in the bed. The 
expression of the face is heavy or vacant. The lips and teeth require 
constant cleansing to keep them from sordes ; the tongue is dry and 
glazed or covered with sordes ; the tendons of the wrists twitch convul- 
sively, and the patient lies with open or half -open eyes (coma vigil), pick- 
ing at the bedclothes or at imaginary objects which float before his eyes. 



THE DATA OBTAINED BY OBSERVATION. 69 

A healthy baby a few months old finds motion an almost ceaseless 
delight. It will lie on its back, kick up its feet, play with its toes or 
some object that attracts it, crowing, wriggling, squirming. In rickets, 
on the contrary, the little patient lies as quiet as possible, even refrain- 
ing from crying, because all motion is painful. In cerebrospinal men- 
ingitis the head is drawn backward and downward and the muscles at 
the back of the neck are rigidly contracted. 

In acute disease involving the peritoneum or neighboring organs, such 
as acute peritonitis, appendicitis, or endometritis, the patient lies on the 
back with the legs flexed upon the thighs and the thighs upon the 
abdomen. Motion is avoided as much as possible, and so is any press- 
ure upon the abdomen. 

The lateral or dorsal position, with legs drawn up and trunk 
and head drawn down to meet them, occurs with groans of pain and 
possibly involuntary bearing-down in hepatic and intestinal colic and 
during the throes of labor. 

The Semi-upright or Upright Sitting Position. In an acute 
attack of asthma the patient is found sitting up in bed, or in a chair, 
possibly by an open window. The expression of the face is anxious, 
the skin dusky or pale, and moist. The breathing is loud, noisy, and 
scraping. The demand for oxygen is imperative, difficulty is experi- 
enced in inspiration and expiration, not enough air for physiological pur- 
poses being able to enter the alveoli ; expiration is prolonged and labored 
(expiratory dyspnoea). The patient sits with the chin raised and head 
erect, the hands grasping the arms of a chair or the bedclothing, so 
that, by fixing the chest, the accessory muscles of respiration can be 
of the greatest assistance in supplementing the diaphragm. In emphy- 
sema, in its late stages, or when complipated with bronchitis and asthma, 
the same position is assumed almost constantly. 

In pericarditis with effusion, in large pleural effusions, and in advanced 
heart disease with anasarca, the patient is unable to lie down on account 
of the smothering feeling which the recumbent position induces. In 
pericarditis the expression of the face is extremely anxious, the patient 
having a dread of impending death. 

In large pleural effusion the expression is not usually so anxious, 
but the dyspnoea may be intense. The patient is propped up in bed, 
leaning slightly to the affected side, and devotes all his energies to 
breathing, avoiding every exertion, such as moving, answering ques- 
tions, or coughing, which taxes his breathing-muscles still more. One 
side of his chest may be observed to move violently while the other is 
motionless. 

In heart disease and anasarca dyspnoea frequently amounts to orthop- 
nea. The patient may be found propped up in bed or seated in a large 
rocking-chair, some patients finding greater comfort in the latter. The 
face is pale, livid, or jaundiced, and may be swollen, while the cellular 
tissue throughout the body is oedematous, and the cavities, especially 
the peritoneum, are more or less filled with fluid. In diaphragmatic 
pleurisy the position assumed is very characteristic — the erect sitting 
posture, with the body leaning forward and laterally, to relieve the 
pain. 



70 GENERAL DIAGNOSIS. 

The Prone Position. Rarely the patient is found lying upon the 
abdomen. He assumes this position because it gives relief to abdominal 
pain or to colic of any form. Owing to the change in the relative posi- 
tions of the organs brought about by this posture, the pain of an ulcer of 
the stomach, of aneurism, or of caries of the vertebrae may be mitigated. 

In tetanus opisthotonos occurs. The body rests on the head and heels 
and the trunk is arched upward, because of tonic contraction of the 
spinal muscles. In strychnine-poisoning with tonic convulsions the 
same position may be assumed. 

Mnprosthotonos, vaulted side position, is occasionally assumed in 
tetanus and also in strychnine-poisoning. 

Unclassified Positions. Irregular or bizarre positions are usually 
assumed in affections of the nervous system, particularly in hysteria. 

Restlessness. Often the patient is unable to assume a position, or, 
at least, to remain fixed in any position. This may occur on account 
of pain, or because of irritation or anaemia of the nerve-centres. In 
cases of moderate cerebral hemorrhage, and of shock, there is great 
restlessness. The patient is restless without the appearance of agita- 
tion. In profuse hemorrhage, whether uterine, intestinal, or pulmo- 
nary, on account of cerebral anaemia, there is also restlessness with 
sighing and gasping. The pallor, the quickened pulse, the great thirst, 
with the history of bleeding, are sufficient to explain the restless state. 
In chorea there is more than restlessness — there is constant twitching 
of muscles with jerking from one side of the body to the other. The 
patient does not keep the covers on when in bed, and by her jerky 
movements often does herself considerable injury. 

In cerebral meningitis the patient tosses from side to side or lies with 
the head retracted and pressed deeply into the pillow. The eyes are 
injected, the pupils contracted, and frequent sharp cries are uttered, 
especially if the patient be a child. 

In hysterical convulsions the patient, usually a young woman, tosses 
wildly to and fro, screaming, laughing, or crying ; or coma may be 
mimicked. The moods often change with great suddenness. The 
appearance is very alarming at first sight ; but the pulse and breathing 
are not much accelerated, there is no fever, and the patient is conscious 
enough not to injure herself even to the extent of biting the tongue. 

Gait. The gait is sometimes characteristic. (See Nervous Diseases.) 
The hemiplegia patient advances the sound limb, and then brings the 
other up to it by lifting the pelvis and swinging the paralyzed limb 
around by a movement of circumduction. The shoe is worn down at 
the toe in an irregular way. Sometimes the shoulder on the sound 
side is thrown outward and forward, so as to facilitate the raising of 
the pelvis on the paralyzed side in order that the limb may be circum- 
ducted. The arm may be rigid or bent at the elbow, the fingers being 
flexed upon the palm and the thumb turned in. 

In locomotor ataxia there is uncertainty in the gait, which may only 
be felt by the patient or be apparent to the observer also. There is 
irregularity in the line of progression, or the movements become very 
jerky and erratic. As there is very little motion at the knee, because 
it is spasmodically braced, the pelvis is slightly tilted until the foot is 



THE DATA OBTAINED BY OBSERVATION. 



71 



released ; the foot is then raised unnecessarily high, jerked rapidly 
forward and outward and brought down with a sudden stamp, or flail- 
like action, on the heel. The patient's centre of gravity undergoes 
several changes at each step, so that he swings from side to side. He 
cannot walk in the dark, and, at a later stage, requires the aid of canes 
to prevent him from falling forward. 

Fig. 2 




Gait in a case of locomotor ataxia ; instantaneous serial photographs. (Muybridge and Dercum.) 



In paralysis agitans the attitude and gait of the patient are peculiar- 
The head and body are thrown forward and fixed in that position ; the 
arms are slightly abducted and partly flexed, the hands being in the 
position in which a pen is held or a pill rolled. The legs are also bent 
at the knees. Rhythmical tremors affect the hands first and then the 
rest of the body, the head and neck usually escaping. On attempting 
to walk the gait is festinating — that is to say, each step becomes more 
rapid than the preceding, until the patient is prevented from falling 
only by catching hold of something. The tremors cease during sleep, 
and are independent of voluntary motion. (See Fig. 3.) 

In spastic paraplegia the patient walks with two sticks. He leans 
on the left one, arches the back, and then lifts the pelvis and the right 
limb as far from the ground as possible, but cannot quite clear it. The 
leg is rigid and the foot dragged around in a semi-circle. The toe has 
a marked tendency to stick to the ground, and is brought forward with 
a scraping sound. The knees have a tendency to interlock, and the 
foot which is brought forward is apt to cross in front of the other. 

In disseminated insular sclerosis the gait is somewhat jerky and resem- 
bles the gait of ataxia or of tumor of the cerebellum. Of course, the 



72 GENERAL DIAGNOSIS. 

disease that causes such peculiarity in gait cannot be established with- 
out first observing the mental and nervous phenomena that attend such 
affections. 



Fig. 3. Fig. 4. 





Side view of a case ot paralysis agitans, show- Spastic paraplegia, cross-legged progression, 
ing forward inclination of trunk. Tendency to (Deecom.) 

propulsion. (Dercdm.) 

In hysterical paraplegia there is sometimes complete loss of power of 
standing or of walking. The patient falls if an attempt is made to 
compel her to stand. Or she walks with the knees and the hips semi- 
flexed or in awkward attitudes, implying greater muscular exertion 
than necessary for the normal gait. It is recognized by the fact of its 
occurrence in young subjects in whom other striking phenomena of 
hysteria are observed. (See page 73.) 

Cross-legged Progression. This form of gait is seen in children with 
spastic paraplegia, and occurs because of contracture in the calf muscles. 
When the child begins to walk, one foot gets over in front of the other. 
Sometimes a swinging oscillation of the body occurs, which may persist 
throughout adult life. (See Fig. 4.) 

The gait of pseudo-hypertrophie muscular paralysis is known as the 
waddling gait. This oscillating character is assumed in order that the 

to bring the centre of gravity over each foot 



THE DATA OBTAINED BY OBSERVATION. 



73- 



011 which the patient successively throws his weight, because the weak 
gluteus medius cannot counteract the inclination toward the leg that is 
off the ground, unless the balance is exact " (Gowers). The position 
assumed in getting up from the floor, as described by Gowers, is pathog- 
nomonic. The patient turns over in the all-fours position, raises the 



Fig. 5. 



Fig. 





! 



'fW 




V 




Hysterical astasia-abasia. (Lloyd.) 

trunk with his arms, rests the trunk 
upon the extended hands, then extends 
the knees, pushes back with the hands 
until he can grasp one knee with the 
corresponding hand, then grasps the 
other knee, and pushes up the trunk by 
gradually raising the point of support 
for the hand upon the thigh. (Fig. 5). 
The swaying gait, like that of a 
drunken man (cerebellar titubation), is 
significant of cerebellar disease. (See 
Station.) 

Feebleness of the gait attends gen- 
eral paresis and the early stage of 
chronic myelitis, but, of course, is of 
no significance unless it is attended by other symptoms of these affec- 
tions. 



Typical pseudo-muscular hypertrophy. 
(Derctjm.) 



74 GENERAL DIAGNOSIS. 

The gait of paramyoclonus multiplex and of Thomsen's disease is also 
peculiar. (See Muscles.) 

Station. Astasia and abasia are terms employed to define the 
loss of power of standing and of walking, respectively, without paraly- 
sis. Both may occur. (See Fig. 6.) They are usually due to hysteria. 

Ataxic Astasia in Locomotor Ataxia. The inability to stand 
is observed under many circumstances. Either with (1) the eyes closed, 
or (2) the eyes open and the toes and heels in contact, or (3) with the 
eyes open and feet apart. The latter occurs in the highest degree of 
ataxia, and may be followed later by complete loss of power of standing. 

Swaying. If a healthy person stands with the eyes shut the body 
will sway slightly. In a patient with locomotor ataxia swaying is 
seen in increased degree. 

In pseudo-hypertrophic paralysis, if the patient stands, there is that 
extreme curvature of the spine known as lordosis. It disappears entirely 
when the pelvis is supported, as in the sitting posture. In the latter 
stages of this affection there is posterior or lateral convexity of the 
spine with astasia. 

In the paroxysms of Meniere's disease the loss of power of standing 
may be absolute. The patient may be hurled to the ground and be 
quite unable to rise or sit up. The nature of the paroxysm is sus- 
pected on account of the sudden onset and the complaint of vertigo, 
together with the ear symptoms that attend this affection. 

In disease of the middle lobe of the cerebellum, sAvaying from side to 
side, or in large waves, is observed. The appearance is like that of a 
drunken person. While the walk is peculiar the patient can usually 
sit up. 

5. General Form and Nutrition. 

The general form and nutrition of the body are estimated by the 
color of the skin, the amount of subcutaneous fat, the degree of muscu- 
larity, the size and shape of the osseous system. Hence we estimate 
the degree of physical development of the individual by the size, the 
weight, and the condition of the muscles, as well as by the state of 
other tissues. To recognize lack of development is often to be able to 
explain phenomena of a functional nature which otherwise could not 
be accounted for. The color will be considered under the head of the 
condition of the skin. 

Importance of such Observation. It is extremely important 
that these observations should be made, particularly in childhood and 
adolescence. Not only are marked departures from the normal signifi- 
cant, but slight deviations point to the occurrence of processes which 
modify nutrition. Unless lack of development is detected, it is fre- 
quently impossible to explain the occurrence of some functional disor- 
der, as neuralgia, or of derangement of the viscera, or of indefinable ill 
health, as the result of which the patient shows inaptitude for exertion 
or inability to conduct the usual affairs of life. The recognition of 
malnutrition, as shown in lack of tone of muscles, or diminution of 
weight, is often sufficient to point the way to successful treatment by 
hygienic methods. 



THE DATA OBTAINED BY OBSERVATION. 75 

Size. Change in size may be general or local. General increase or 
diminution in size, not necessarily abnormal, is due to enlargement or 
diminution of the muscles and fat, singly or combined. When large 
accumulations of fat take place the word obesity is applied to the con- 
dition. The estimation of the patient's size as compared with his weight 
is usually based upon the amount of subcutaneous fat. The general 
accumulation can readily be recognized by rotundity of the exterior. 

Size affords some information as to the degree of development of our 
patients and as to the kind of diseases to which they are most liable. 
While there is no absolute standard by which to compare the relative 
proportion of height to girth in individual cases, yet there is a type 
generally recognized as being usual, and variations from it give rise to 
such expressions as stout, spare, slender, thin, tall, and short. Stout 
usually expresses an increase in girth and a moderate excess of flesh 
over the normal. When used in this sense it becomes synonymous 
with lusty, and indicates an increase of flesh which is well distributed 
and due to healthy, active nutrition without impairment of physical 
activity. In some cases, especially in women, stoutness is used as a 
euphemism for corpulency, but not often for that excess of fat properly 
called obesity. Stoutness, in the sense of lustiness, up to middle life is 
an indication of physical and often of mental vigor. It is often found 
in gouty and rheumatic subjects. A tendency to take on flesh after 
the age of forty-five, especially if the person's occupation is sedentary 
and his habit of body inactive, is not to be regarded as favorable. It 
may be compared to a warrior's persisting in wearing an increasingly 
heavy weight of armor after the campaign is over. Increased weight 
under such circumstances is not increased strength, but increased 
burden, and the burden becomes greater with advancing years. Those 
avIio are under forty and stout, in the sense of having too much fat in 
proportion to bone and muscle, bear fevers and exhausting diseases 
badly. Women at the menopause are very prone to take on flesh 
rapidly. Fat subjects after middle life, and to an increasing degree 
after that period, are liable to fatty degeneration of the heart, blood- 
vessels, and important viscera. 

Persons who are tall and thin, especially if they have become tall 
rapidly after puberty, are commonly looked upon as delicate, and as 
especially liable to consumption. There is reason for this view. But 
if they live to be twenty-five or more, without disease of the lungs or 
pleura, they may then live to a great age. 

Some patients have an appearance which is well described and under- 
stood by the word "spare." The form is compactly put together, but 
with small bones and a scanty allowance of fat. There is a tendency 
to leanness rather than to roundness of form. 

In still others muscle and bone predominate, and the form is apt to 
be angular, as in those described as wiry. They are often possessed of 
great muscular power and resistance to strain. Those of spare and 
wiry habit bear disease very well. Inspection alone may leave one in 
doubt whether to regard an individual as thin and delicate or spare. 
Light will be obtained from the patient's occupation and the amount 
of physical exertion of which he is capable, and also from the tonicity 



76 GENERAL DIAGNOSIS. 

and hardness of his muscles. If one stops to think a moment, he will 
see that, for the same amount of heart and lung capacity, a man will 
be better off if spare than if corpulent ; because in the latter case he 
has an additional load to carry, and he has to nourish and keep up a 
thick blanket of fat from which he derives no adequate advantage. 
Hence a person of spare build, who survives childhood and adolescence 
without disease, probably has, on the whole, a better prospect for long 
life than a stout person. 

Normal Habit. In estimating the patient's size or weight it is 
important to ascertain if he has a regular habit of taking on flesh at 
certain periods of the year, for instance, or if it has developed suddenly 
or followed acute disease. 

Weight. Xothing has yet been said of the weight, but, as it affords 
a precise estimation of the size, particularly if considered in relation 
to the height and age, the following discussion will include the two- 
points, size and weight. 

While the eye can estimate approximately the weight of the body 
and the degree of emaciation, the physician should make it a rule to 
ascertain the weight accurately by means of scales. Machines are 
now made which can be used for weighing the patient and at the same 
time noting the exact height. It is particularly important to note the 
weight from time to time. In the course of wasting disease we learn 
the effects of treatment, or, on the other hand, the march of disease in 
spite of treatment. In obscure cases, as in tuberculosis, persistent loss 
of flesh is a serious diagnostic and prognostic symptom. After acute 
disease, if the patient is weighed every week, the onset of insidious 
sequelae, as tuberculosis, may be detected. 

The relation of body- weight to height is of importance. It is also 
important to know the average weight of the individual in different 
periods of life. The progressive increase in weight which should take 
place after birth should be remembered, as the opposite is positive 
evidence of malnutrition. 

Mr. Hutchinson's table enables us to judge the average weight of a 
healthy man of a given height : 

A man of 4 ft. 6 in. to 5 ft. in. ought to weigh about 92.26 lbs. 

" 5 " " 5 " 1 " " " 115.52 " 

it << 5 u 2 << 5 " 3 " " " 127.86 " 

" 5 " 4 " 5 " 5 " " " 139.17 " 

" 5 " 6 " 5 " 7 " " " 144.29 " 

" 5 "8 " 5 " 9 " " " 157.76 " 

" 5 " 10 " 5 " 11 " " " 170.86 " 

" " 5 " 11 " 6 " " " " 177.25 " 

In some life insurance tables in this country the average weight for 
the height is lower, especially in persons over five feet ten inches. 

Weight ix Disease. The question of weight is an important one 
in disease. As has been stated, persons with an excess of fat do not 
bear fevers and exhausting processes so well as those who have a 
relatively larger proportion of firm muscles. Remember, if emaciation 
is present, to ascertain its amount and degree, its possible relation to 
unusual mental care or to acute disease. Slow progressive emaciation 



THE DATA OBTAINED BY OBSERVATION. 77 

is of serious moment, as evidence of tuberculosis or disorder of assimi- 
lation. Remember the wasting that is associated with great hunger, 
excessive thirst, and polyuria in diabetes mellitus. On the other hand, 
such symptoms as occasional cough, slight evening fever, and impair- 
ment of resonance at one apex of the lung become much more signifi- 
cant of incipient phthisis if accompanied by loss of weight. At any 
stage of phthisis a maintenance of the body-weight is one of the most 
favorable elements in prognosis. 

Again, while loss of weight attends all the diseases of the digestive 
tract which interfere seriously with nutrition, it progresses more rapidly 
and steadily, and attains a greater degree, in malignant disease than in 
the mechanical or functional diseases. Hence the question of loss of 
Aveight is important in deciding between chronic catarrhal gastritis and 
gastric carcinoma. But still more important is the question of the time 
during which loss of flesh has been taking place, and whether it has 
been progressive or interrupted by periods of gain in weight. If during 
two or three years the patient has been vomiting occasionally, and 
losing flesh, but gaining again from time to time, it is much more 
significant of gastric catarrh than of gastric cancer. 

False Increase of Weight. In certain cases of great anasarca, 
and in malignant disease of the abdomen, especially huge cysts of the 
ovary in women, and sarcoma of the kidney in children, there may be 
actual increase of weight due to the accumulation of water or to the 
new growth, though the rest of the body is manifestly emaciated. 

Weight in Children. In babies and children fat is more likely 
to be a sign of good health than in adults. Nevertheless the quality 
of the flesh is to be taken into consideration. There are fat and flabby 
babies and children, and there are others who are fat but whose flesh 
has a firm, solid feel. The former often gain and lose flesh rapidly, 
and, when ill, do not appear to have much resisting power. The size 
of a child gives a good idea of its nutrition. A child may have its 
growth stunted by bad food and unfavorable hygienic conditions, or 
the stunting may be the result of exhausting disease, such as whooping- 
cough. 

Increase in size and weight then may be due to changes in (1) the 
skeleton (see Chapter XIII.) ; (2) the muscles ; (3) the adipose tissue ; 
(4) the subcutaneous connective tissue, giving rise to accumulations of 
serum, mucin, or connective tissue dystrophies (see Chapter X.). 
Diminution in size is due to changes in (1) the skeleton ; (2) the 
muscles, and (3) the adipose tissue. The word emaciation is applied 
to excessive atrophy of fat and muscles. If it is accompanied by 
great exhaustion and apparent loss of fluid, the word marasmus is 
employed. 

Degree of Loss. The whole body may exhibit considerable loss 
of flesh, the cheek bones and temporal fossae being distinctly visible, 
the muscles soft, the limbs wasted, and the subcutaneous fat dimin- 
ished. It is important to notice whether flesh has been lost or not, 
and how much, and how long a time the loss has been going on. Such 
facts furnish the clue not only to diagnosis but to treatment also. 
Flesh is lost in almost all diseases, acute or chronic, but it becomes of 



78 GENERAL DIAGNOSIS. 

special moment in diagnosis in the latter. It is most noticeable in 
tuberculosis, cancer, marasmus, cirrhosis of liver and kidneys, diabetes, 
in anaemias, and in cachectic conditions due to prolonged suppuration 
or chronic diarrhoea, in gastric neurasthenia and anorexia nervosa. 

Local Change in Size. There may be local increase or diminu- 
tion in size, alone or combined. It is not to be forgotten that accumu- 
lations of fat may take place in special portions of the body ; the abdo- 
men is the favorite seat for excessive accumulation, particularly in 
women and in men of sedentary life, with habits of excessive indul- 
gence in food and drink. When one part is increased in size and 
another growing progressively small the disparity indicates disease (see 
below). The face is swollen, especially under the eyes and above the 
jaws, in the dropsy of large white kidney and in parotitis. The neck 
may be enlarged in the sterno-clavicular notch or laterally above the 
clavicles in aneurism. The thyroid, as a whole, or either lobe, is 
enlarged in goitrous affections and in Graves's disease. 

The face may be thin and even much emaciated, while the abdomen 
is greatly distended from dropsy or from tumors of the various abdom- 
inal viscera or glands. The chest is enlarged or contracted. Local 
decrease in size in thorax or abdomen is significant of tumors. 

The head is much increased in size in chronic hydrocephalus, while 
the face remains small. The bones of the cranium are enlarged in 
leontiasis ossea. The head, face, and neck enlarge in the affection 
described by Allen Starr as megalocephalie. (See Chapter VII.) 

The loss in flesh in the extremities or special muscles may be local 
and atrophic in character, as in some diseases of the nervous system, 
such as neuritis, infantile palsy, hemiplegia, and monoplegia. Loss of 
flesh of the arms is said to be a symptom in cystic ovarian tumor. 

The increase in size may also be local, as in hydrocephalus, elephan- 
tiasis, dystrophies, myxoedema, oedema, and various tumors. 

The General Musculature. The state of the muscles must 
always be learned. It has been referred to in the discussion on emacia- 
tion. A few words more seem necessary. It must be remembered that 
a person can be obese and yet have poor muscular development, or have 
little fat and fair muscle. General lack of muscular development or 
muscular weakness is an important sign of malnutrition, and may ex- 
plain the nature of many symptoms. The muscular weakness can be 
approximated by the degree of firmness of the muscle. Weakness of 
the muscles of the spine, with resulting curvature, or inability to keep 
the erect posture, is sufficient cause for the occurrence of neuralgic 
pains in the course of related nerve-trunks, and for the displacement of 
organs within the thorax or abdomen, often causing functional dis- 
turbance. Various uterine displacements and functional disorders may 
be mitigated by toning up the nutrition of the muscles of the trunk. 
Forms of indigestion, sluggishness of secretions, particularly of the 
bowels, follow in the wake of debilitated muscles and pass away as such 
muscles gain tone. It may be that the indigestion has not taken place 
because the muscles are weak, although in a measure there is relation 
between them ; but the weak, flabby muscles are pronounced indica- 
tions of a state of the system which may develop indigestion. More- 



THE DA TA OB TA IN ED B Y OBSER VA TION. 7 9 

over, weakened abdominal walls, separated recti muscles, and diastasis 
favor dropping of the liver, stomach, and other organs, causing gastro- 
enteroptosis with its train of symptoms. The detection of muscular 
deficiency leads to correct lines of treatment. Atrophy of muscles 
occurs because of disuse, because of sedentary occupation or of a life 
of ease and luxury, with improper nutrition. It is sure to follow im- 
proper assimilation, as seen in extreme degree in anorexia nervosa. 



CHAPTER VII. 

THE DATA OBTAINED BY OBSERVATION— {Contin ued). 

The face — the facial expression. The head. Mumps — facial hemiatrophy. Hydro- 
cephalus. The hair. The lips. The neck — the thyroid gland — exophthalmic 
goitre — the bloodvessels of the neck. 

The Face and its Expression. 

The face is a mirror in which are reflected all degrees of ill health, 
from that which amounts only to temporary indisposition and depres- 
sion up to the gravest cachexia. The face reflects also the degree 
of intelligence of the patient and his mental condition at the time, as 
well as his emotions, and, in a large measure, his character. The face 
is usually a fairly good index of the temper of the individual ; benev- 
olence, amiability, and purity are written as plainly on some faces as 
anger, lust, dishonesty on others. (See Nose and Mouth in respective 
chapters on special diagnosis.) 

The face frequently affords us valuable information concerning the 
health, habits, and temperament of the individual. Everyone is 
familiar with the bright eye and animated countenance of a friend 
which lead us to say, " You are looking very well to-day," and with 
that slight pallor, diminished clearness of the conjunctiva, with per- 
haps a dark circle under each eye, which lead us to infer that he is 
depressed or has passed a sleepless night. The face also gives unmis- 
takable evidence of alcoholism by its bloated appearance, injected or 
glassy eye, dull expression, and nervousness when the patient is 
addressed suddenly. 

Full-blooded persons, disposed to endarterial changes, frequently as 
the result of gout, often have, at a little distance, the ruddy appearance 
of blooming health. Closer inspection, however, shows that the ruddy 
color is due to a dilated or congested condition of the minute blood- 
vessels. This condition, when associated with high tension in the arte- 
ries and accentuation of the aortic second sound, is highly suggestive 
of chronic nephritis. (For color and complexion, see the Skin, Chapter 
X.) 

Moreover, the face tells of the presence or absence of pain, and, to a 
certain extent, of its character. Everyone has witnessed the sudden 
contraction of the brow and eyelids and the involuntary sucking in of 
the breath when some one has bitten upon a tender tooth. Other faces 
bear the imprint of long-continued more or less constant suffering. 
According to Eustace Smith, pain in the head in children is indicated 
by contraction of the brows ; pain in the chest, by sharpness of the 
nostrils ; and in the belly, by a drawing of the upper lip. (See the 
Face in Children and Pain, Chapter IV.) 



THE DATA OBTAINED BY OBSERVATION. 81 

It will be seen that the expression, the color, and the outline of the 
face are valuable indications of disease. 

The master mind in clinical medicine, the late Austin Flint, Sr., 
tersely described the various appearances of the face in disease, with 
their clinical significance, as follows : 

The Facie s of Renal Disease. In some cases of acute albuminuria 
and of chronic parenchymatous nephritis — the large white kidney of 
Bright — puffiness of the face from oedema, with notable pallor, renders 
the aspect highly diagnostic. 

The Malarial Facies. Pallor of the face, sallowness, and slight 
puiimess, if renal disease be excluded, point to malarial disease. 

The Facies of Carcinoma. Notable anaemia, a waxy or straw- 
colored complexion, and more or less emaciation, in combination, render 
the aspect marked in some cases of malignant disease. In a patient 
over forty years of age this aspect has considerable diagnostic import, 
although it is by no means always present when malignant disease exists. 

The Typhoid Facies. In the middle and later periods of typhoid 
fever the countenance is often dull, besotted, expressionless. This 
facies may be present in the typhoid state, which is incident to diseases 
other than typhoid fever — e. g. y pneumonia. Coexisting with a dusky 
hue of the skin and congestive redness of the conjunctiva, it distin- 
guishes typhus as contrasted with typhoid fever. 

The Facies of Acute Peritonitis. The upper lip raised so as to 
expose the front teeth gives an aspect which characterizes, in a certain 
proportion of cases, acute peritonitis. It is often wanting, but when 
present it is strongly diagnostic. 

The Facies of Acute Pneumonia and Hectic Fever. Circum- 
scribed redness of one or both of the cheeks, with abruptly defined 
borders, is diagnostic of acute pneumonia. If it be observed in a case 
of chronic pulmonary disease it denotes the so-called hectic fever, and 
is a sign of phthisis. The wan, emaciated appearance with the bright 
eye and hurriedly expanding nostrils excites our fears that the progress 
of the latter affection is most rapid. 

The Facies of Exophthalmic Goitre. Projection of the eyeballs, 
giving to the face a remarkably staring and sometimes ferocious ex- 
pression, conjoined with enlargement of the thyroid body and frequency 
of the pnlse, is distinctive of the affection known as exophthalmic 
goitre — Graves's or Basedow's disease. 

The Choleraic Facies. In the collapse stage of cholera the face is 
contracted, sometimes wrinkled ; the cheeks are hollow, the eyes sunken, 
the skin is livid, and the expression denotes indifference. This com- 
bination of traits is quite distinctive. They are, however, to a certain 
extent combined in the state of collapse which occurs in some cases of 
pernicious intermittent fever and in other pathological connections. 

The Hippocratic Facies. This facies denotes the moribund state. 
The skin is pale, with a leaden or livid hue ; the eyes are sunken, the 
eyelids separated, and the cornea loses its transparency ; the nose is 
pinched and the eyes are contracted ; the temples are hollow and the 
lower jaw drops. Hippocrates described this facies in graphic terms, 
and the name Hippocratic has ever since been used to designate it. 



82 GENERAL DIAGNOSIS. 

The Face in Children. Inspection is even more important in the 
case of children than in adults. The pale, pinched, weazened face of 
some babies who have snuffles, ulcers, or striated lines at the corners 
of the mouth, and look prematurely aged, with prominent forehead and 
a depressed nasal bridge and retrousse" tip, characterizes inherited syph- 
ilis. In older subjects the undeveloped face and skull are striking. 
In rickets the head is unusually large with flattened vertex, projecting 
forehead, and open fontanelle. In hydrocephalus the head becomes 
very much enlarged, the eyes prominent, the bones of the face remain- 
ing small, the expression vacant. In adenoid disease of the pharynx, 
with tonsillar hypertrophy, the dull apathetic expression, with the 
thickened lips, the small nasal orifices, and the gaping mouth are char- 
acteristic. In cretins the thickened lips, the protruded tongue with 
saliva dribbling from the open mouth, the flattened nose, with the 
idiotic expression and pallid, waxy skin, are easily recognized. ■ To a 
lessened degree such appearances are seen in " backward " children, 
who, it may be said, are undeveloped cretins. In measles the red, 
swollen face, the reddened, weeping eyes, and running nose make a 
very striking picture. An irritating, excoriating discharge from the 
nose in a child may indicate the existence of a nasal diphtheria. 

The Face in Nervous Disease. All varieties of mental aberration 
are reflected in the face ; the suspicious, at times revengeful, look of 
the delusional monomaniac ; the wild look and excited manner of the 
maniac ; the plaintive, depressed, injured look of melancholia ; the 
vacant, listless, peaceable, animal-like look of dementia — a look which 
changes to animation only at the sight of food or some coveted luxury. 
All these expressions come to be recognized very readily by those who 
see much of the insane. In addition, in hysteria expressions of varied 
emotions are seen ; in neurasthenia a worn and wearied aspect of coun- 
tenance is noticeable. 

The face often tells of the existence of some organic nervous dis- 
order. The peculiar heavy expression, drooping eyelids, though they 
close improperly, and sluggishly moving lips, betoken the early stage 
of the facio-humero-scapular type of muscular atrophy, and is some- 
times seen in Friedreich's ataxia. 

Change in the expression and appearance of the face more frequently 
occurs because of change in the function and nutrition of the muscles, 
on account of central or peripheral disease of the nervous system. On 
this account we have facial spasm or tremor, and unilateral, bilateral, 
or local facial paralysis. Further consideration of these conditions will 
be found in the local examination of the muscles (Chapter XII.) and 
in Diseases of the Nervous System. 

In peripheral facial palsy the paralyzed side of the face has a staring, 
vacant expression, owing to the fact that the eyelid is motionless. 
The angle of the mouth on the affected side is depressed. The whole 
paralyzed side is devoid of wrinkles, has a smoothed-out, glazed appear- 
ance ; tears flow over the cheeks and saliva dribbles from the corner 
of the mouth. The contrast with the normal side is most marked when 
the patient smiles or frowns. (See Fig. 7.) 

In glosso-labial pxdsy there is progressive palsy, with tremulousness 



THE DA TA OB TAIN ED B Y OBSEB VA TION. 83 

of tongue and lips ; progressive failure of articulation and dribbling 
of saliva. Sometimes the patient is able to open the lips but unable to 
close them without the aid of the hand. In paralysis agitans the mask- 
like expression of immobility has been described as Parkinson's mask. 

A slow, hesitating, thick manner of speaking, with a tendency to 
slur the labial and lingual consonants, when associated with irregu- 
larity of the pupils, slight tremulousness of the lips, and the loss of the 
fine adjustment of other muscular movements, such as writing, is very 
suggestive of general paralysis of the insane, especially when the condi- 
tion develops in a middle-aged man. 

Facial hemiatrophy is a peculiar affection, characterized by pro- 
gressive wasting of the bones and soft tissues of one side of the face. 
The disease is rare ; it begins, as a rule, in childhood, but may develop 
in later life. The local change is diffuse ; in some instances, however, it 
slowly spreads from a spot in the skin, involving, in succession, the 
tissues underneath. The skin changes in color and the hair falls out. 
The eye is sunken on the affected side, on account of wasting of the 
tissues of the orbit. The bone of the upper jaw atrophies to a more 

Fig. 7. Fig. 8. 





Complete facial palsy. Patient unable to close eye 

of the affected side. (Dercum.) Facial hemiatrophy. (Lyman.) 

advanced degree than the other bones which undergo wasting. Because 
of the wasting of the alveolar processes the teeth become loose and fall 
out. The wasting is sharply limited by the middle line. (See Fig. 8.) 
The disorder is easily recognized. The patient looks as if the face were 
made up of two halves from different persons. It must not be mistaken 
for facial asymmetry that is associated with congenital wry-neck. The 
contraction of the sterno-mastoid muscle from birth distinguishes the 
affection. 

The outline of the face and any change in the shape of the head 
should next be observed. Both changes, as seen in myxwdema and 
scleroderma (see Skin, Chapter X.), are described. The striking changes 
in acromegalia, rickets, and osteitis deformans are described in Chapter 



84 GENERAL DIAGNOSIS. 

XIII. , on Bones and Joints. In leprosy the face is characteristic ; 
the leonine countenance — -faeies-leontina — is the result of the tuberous 
outgrowths about the eyes and forehead. 

Enlargement of the Face. Swelling. Other changes in the out- 
line of the face and skull are significant. The face is swollen and 
deformed in erysipelas and smallpox, and, to a moderate degree, in 
measles. The specific eruption serves to distinguish each one. The 
pumness of the eyelids and general swelling of the face in the course of 
Bright' s disease will be referred to. (See OEdema.) 

CEdema of the face occurs in trichinosis. It occurs at two periods in 
the course of the disease. It is seen in the eyelids in the beginning of 
the disease and disappears after a few days. Later it returns with 
pain, tension, and restriction of the movement of the eye-muscles. 

Mumps. In mumps the swelling is characteristic. It usually begins 
on one side. The swelling of the parotid gland is observed in front of 
the ear, then it extends below and around it and behind the ramus of 
the jaw. Unless there is much collateral oedema the outline of the 
gland is preserved. The gland is tender and boggy, not indurated. 
Viewing the face from the front, the midlateral aspects are seen to 
bulge. The ears stand out from the head. The jaws are fixed. The 
submaxillary glands are usually enlarged. 

The data to be considered in the study of an infectious disease are 
pointed out in the chapter devoted to those affections. In addition 
to such data the diagnostic features of mumps are the symptoms of 
the invasion of the general symptoms and the local signs. 

The symptoms of the invasion are sudden, with chilliness, a rise in 
temperature, which is generally moderate (101° to 103°), and pain at 
the angle of the jaw. The corresponding parotid rapidly begins to 
swell, as well as the adjacent cellular tissue. Along with pain on 
movement of the jaws, any acid liquid, as vinegar, which stimulates 
salivary secretion, increases the pain. At times the submaxillary 
glands are involved instead of the parotids, or they may be enlarged 
and painful several days before the parotid is affected. The disease 
may be limited to one side or involve the opposite side, as the process 
in the one first attacked subsides. Rarely it is bilateral from the start. 
When the swelling has lasted from three to five days the fever sub- 
sides and the swelling begins to disappear rapidly. At this time, how- 
ever, the opposite side may be attacked or the testicles become inflamed. 
Usually it is the right testicle. In girls and women the ovary or 
mamma is rarely inflamed. Resolution is extremely rapid, and usually 
the disease is not followed by sequelae. Sometimes, however, deafness 
is left. In fact, sudden deafness sometimes announces the commence- 
ment of an attack. 

If to these facts we add the data obtained in the social history, the age 
of the patient under fifteen, and the history of exposure or the presence 
of an epidemic, the diagnosis is easily made. 

It must be borne in mind that parotid swelling, inflammation, with 
or without suppuration, may occur in the course of various infections, 
notably typhoid fever and septicaemia. It may also be traumatic. 
Chronic enlargement of the parotid occurs in syphilis. In some cases 



THE DA TA OB TAINED B Y OBSER VA TION. 85 

(Osier and Kiimmel) the submaxillary and lachrymal glands are con- 
jointly enlarged with the parotid. 

The Lips. Color. The lips are pale in anaemia, and livid in 
cyanosis from chronic lung or heart disease with feeble circulation. 
Vesicles (herpes) are apt to appear upon them in common colds, in cer- 
tain febrile diseases, particularly pneumonia, and with many women 
during or immediately following menstruation. A child with heredi- 
tary syphilis may show ugly fissures, or the scars which result from 
them, at the angles of the mouth. In facial palsy the angle of the 
mouth on the paralyzed side is depressed and free from wrinkles. In 
glosso-labial-laryngeal palsy the lips tremble, twitch, and may have to 
be closed with the fingers after they have been opened. In general 
paralysis of the insane the lips tremble, and speech is " thick,' 7 hesi- 
tating, and uncertain, with a tendency to elide syllables and slur the 
labial consonants. 

Hair. The hair often indicates the state of the nutrition of the indi- 
vidual. Changes in it may be significant of syphilis or other internal 
morbid processes. The abnormal growths and changes in the texture 
due to local parasitic disease will not be referred to. Undue and rapid 
falling out of the hair in patches, known as alopecia, is indicative of 
syphilis and of profound intoxication by the virus of this disease. The 
hair can be pulled out in large masses without difficulty or pain. This 
falling of the hair must not be confounded with the excessive falling 
out which takes place in the convalescence of acute disease, particularly 
of typhoid fever, nor with that following an attack of gout or erysipelas. 

Color op the Hair. Obscure paralysis or anaemia may be ex- 
plained by noting if the hair is artificially colored. Lead and other 
poisonings have repeatedly arisen from the use of hair-dyes. Other 
changes in the color are often significant. Early gray hair may go 
hand-in-hand with premature endarteritis. The term " canities " is 
applied to the diminished development of pigment. Premature gray 
color in defined patches occurs in nerve-lesions, as paralysis of one of 
the branches of the fifth pair, and is a trophic change. Sudden change 
in the color of the hair, usually to gray, takes place at times under the 
influence of fright, mental anxiety, or deep emotion. 

" Green " hair is seen in brass-founders and workers in copper-mines ; 
• ' blue " hair in laborers in cobalt-mines and persons employed in the 
manufacture of indigo. Chemicals applied to the hair change its color 
— peroxide of hydrogen bleaches the hair, pyrogallic acid turns it 
black. Drugs administered internally, as jaborandi and its alkaloid, 
change the color to dark hues. 

The Head. 

The posture of the head and abnormal movements are due to affec- 
tions of the muscles of the neck, and will be considered in a study of 
local affections of muscles. (See Chapter XII.) 

Enlargement. Change in the size and shape of the head is seen 
in rickets, acromegalia, and otitis deformans, along with other skeletal 
changes, and are discussed in the chapter on the Bones and Joints. 



86 



GENERAL DIAGNOSIS. 



Enlargement is due, however, to local hypertrophy of the bones, to 
hypertrophy of the soft tissues (myxoedema and leprosy), and to 
enlargement of the contents of the cranium. Enlargement of the bones 
is seen in leontiasis ossea. In osseous hypertrophy the bones are thick- 
ened. Gowers states such thickenings may simulate hydrocephalus at 
any age. He thinks it doubtful whether the nature of osseous hyper- 
trophy can be ascertained during life. 

Enlargement due to increase of cranial contents is seen in hydro- 
cephalus. 

Hydrocephalus. The enlargement of the skull is very conspicuous, 
and the disproportion of the cranium to the face is striking. The 
cranium is rounded or globular in shape, and the fontanelles are seen 




Congenital hydrocephalus. Female, aged seventeen, 
of the hair could not be represented. 



(The thinness 



to be very large, tense, and bulging, and the sutures widely separated. 
The disproportion in size between the face and head is increased by the 
projection of the anterior portion of the skull. The axis of the eyes is 
directed downward, and they are partly covered by the eyelids, because 
of the oblique direction of the orbital plates. The head is supported 
with difficulty. The eyeballs roll from side to side. There is frequently 
strabismus. The skin is stretched tightly over the cranium, and the 
hair is scanty. (See Fig. 9.) 



THE DATA OBTAINED BY OBSERVATION. 87 

Diminution in the size of the head is seen in microcephalia (circum- 
ference less than seventeen inches). It is usually abnormal in shape. 

Fontanelles. After a consideration of the size and shape of the head 
we turn our attention to an examination of the fontanelles and the 
bones of the head. The fontanelles in a healthy child, with the excep- 
tion of the anterior, close in the early weeks of life. The anterior 
close from the sixteenth to the twentieth month. We note whether 
they are open or closed, prominent or depressed. New openings or fon- 
tanelles and loose bone plates, the normal fonanelles remaining open, are 
seen in so-called craniotabes — a condition found in congenital syphilis 
and rarely in rhachitis. 

Prominence or fulness may be temporary or permanent. When the 
former, a passing fever with cerebral congestion may be the cause ; 
when the latter, hydrocephalus and other brain affections in which 
there is increase of internal pressure. Depression of the fontanelles 
occurs in general atrophy, marasmus, and in wasting diseases generally. 
It is present in collapse, and is of grave prognostic omen. In pneu- 
monia and other respiratory affections with dyspnoea, retraction is 
observed. The former affection, with cerebral symptoms, is thus dis- 
tinguished from cerebral meningitis in which the fontanelles bulge. 
The fontanelles are neither prominent nor depressed in rickets, a point 
of distinction between this affection and hydrocephalus or enlargement 
from other internal causes. They may remain open, moreover, long after 
the usual period of closure in rhachitis, even to the third or fourth year. 

The Bones. The bones of the cranium may be thickened ; they 
may be the seat of periostitis, of necrosis, and caries. Xecrosis and 
caries of the frontal bone are almost pathognomonic of syphilis. Necro- 
sis of the jaw bone belongs to phosphorus-poisoning. The mastoid and 
petrous portions of the temporal bone should be examined in many 
affections. The symptoms that should call our attention to these bones 
are pain and tenderness over the mastoid, rigors, and fever, with the 
symptoms of thrombosis of the cerebral sinuses, pain in the head, con- 
vulsions, and strabismus. Examination in this region should extend 
to the occipito-atlantal articulation. Disease of this articulation, and 
particularly tubercular disease, causes stiffness of the neck or falling 
forward of the head. On account of the stiffness, associated with diffi- 
culty of deglutition and pain, the writer has seen it mistaken for retro- 
pharyngeal abscess. 

Auscultation and percussion. We have thus far limited our examina- 
tion of the head to inspection and palpation. Auscultation has been 
practised, and at one time it was thought the continuous murmur heard 
over the vertex in children was due to intracranial disease. Osier, 
however, pointed out its occurrence in healthy children, hence, unless 
heard in adults, its presence is not of diagnostic significance. McEwen, 
of Glasgow, has found that in cerebral abscess and tumor and also in 
meningitis, secondary to ear disease, a difference in the percussion-note 
was found over the affected area, and at the same time the percussion 
resistance was increased. The site of disease was indicated by a note 
higher in pitch than the usual osteal note. Comparison of the two 
sides must be made. 



88 GENERAL DIAGNOSIS. 

The Neck. 

The position and movements of the larynx and trachea, the thyroid 
gland, the lymphatic glands, and the vessels of the neck should be 
observed. 

The larynx and trachea occupy the median line in health, but may be 
deflected to the right or left. The deflection is more readily noticed at 
the lower part of the neck, and can be ascertained by comparing its 
position with the normal relation to the adjacent muscles. The change 
in position is due to disease within the thorax. An aneurism or a 
mediastinal tumor may cause this alteration. In cases of chronic 
fibroid phthisis the trachea is pulled to the side of the affected lung. 
When the respiratory movement of the larynx and trachea is excessive 
and associated with dyspnoea the source of the dyspnoea is of laryngeal 
origin. When, on the other hand, the movements are lessened, or the 
organs remain fixed, notwithstanding violent efforts at respiration, the 
dyspnoea is due to disease in the mediastinum, as enlargement of the 
mediastinal glands, or aneurism pressing upon a bronchus. Tracheal 
tugging may be seen, but is usually determined by palpation. It is 
particularly characteristic of aneurism of the descending portion of the 
aorta. The aneurismal sac presses upon the bronchus, and, with each 
pulsation of the vessel, tugs or pulls downward upon the trachea, which 
tugging is transmitted to the hand. (See Diseases of the Vessels.) 

Thyroid Gland. It may be enlarged or atrophied. Atrophy is 
shown by absence of fulness, which would otherwise be present. (See 
Myxoedema and Acromegalia.) 

Enlargement of the thyroid can be detected without much 
difficulty. It may be limited to one lobe, or both lobes may be affected. 
It may vary in size from a small localized swelling to large masses 
which fill the median and lateral sides of the neck, pressing upon the 
trachea and extending into the thorax. On palpation the swelling may 
be soft or hard. In the fibrous forms the swelling is not very large 
and is very much indurated. In the cystic forms of the thyroid en- 
largement fluctuation may often be detected ; it may be localized to a 
small area of the lobe, or may be detected over the entire affected lobe. 
In some cases, on palpation, a purring or thrill is transmitted to the 
fingers. The thrill is synchronous with the heart's action and due to 
increased vascularity of the gland. Auscultation under these circum- 
stances reveals a systolic murmur. 

Causes. Enlargement of the thyroid gland may be due to simple 
hypertrophy, to fibro-cystic enlargement, or to enlargement in which 
the vascularity is more prominent, as in exophthalmic goitre. 1. In 
simple hypertrophy the enlargement is often intermittent, increasing 
in size at each menstrual period, or coming on in pregnancy, to disap- 
pear after labor. It may then disappear entirely or return at the 
menopause. 2. The fibro-cystic enlargement which occurs in countries 
in endemic form is persistent. 3. The enlargement of exophthalmia 
generally continues throughout the course of the disease. (See below.) 

Exophthalmic Goitre. Exophthalmic goitre, Graves's or Basedow's 
disease, is far more frequent in women than in men. It may develop 



THE DATA OBTAINED BY OBSERVATION. 89 

at anv age, but is most common in early adult life. A neurotic hered- 
ity, exhausting disease, general debility, and anaemia are predisposing 
causes, while sudden fright or shock is the most common exciting 
cause. Graves's disease begins slowly. 

The data just recorded are those of the social and family history, and 
with the objective symptoms to be described complete the picture of 
this affection. 

Of the three classic symptoms, rapidity of the heart's action, with 
palpitation, enlargement of the thyroid, and prominence of the eyes (exoph- 
thalmos), the first is the essential symptom. It is also usually the 
earliest. Either enlargement of the thyroid or exophthalmos may be 
absent for months or years, and in some instances throughout the disease. 

1. Tachycardia. Attacks of palpitation may recur at intervals for 
a long time before their true nature is suspected. In these attacks the 
behavior of the heart is much like that which occurs under the influence 
of fright or great excitement. The frequency may not be over 100 or 
120 in the early attacks, the rate being normal in the intervals. In the 
later and severe attacks, however, the pulse beats 160 or 180 or even 
200. It is small and regular. The heart beats with increased force ; 
the sounds are loud, sharp, and clear, occasionally being heard several 
feet from the patient. In time the heart becomes hypertrophied and 
dilated, and there is often a loud, basic, systolic murmur. 

The larger arteries and even sometimes the smaller ones show the 
vascular disturbance by increased pulsation, sometimes with thrill. 

2. The Thyroid Glaxd. The thyroid is usually the next to be- 
come affected. It enlarges slowly from vascular dilatation, the swell- 
ing at first subsiding in the intervals between attacks, but subsequently 
persisting. The right lobe may be larger than the left. The enlarge- 
ment is painless, soft, and compressible. It may pulsate with or with- 
out thrill, and over it can be heard hamiic murmurs. 

3. The Eyes. Prominence of the eyes is the most conspicuous 
feature of well-marked cases. Like enlargement of the thyroid, it 
varies in degree, and rarely is wholly absent. The protrusion allows 
the white sclerotic to show above and below the cornea, giving the eyes 
an unnatural, startled, staring appearance. The protrusion may be so 
great that the eyelids cannot close ; more commonly they close, but 
when the eyeball is simply directed downward the upper eyelids do 
not follow but remain spasmodically elevated or lag behind the move- 
ment of the eyeball (Yon Graefe's sign). The eyeball may become 
inflamed and even slough from undue exposure. In rare instances one 
eyeball alone is affected, and in these cases the lobe of the thyroid of 
the opposite side is enlarged. Stelwag's sign (widening of the palpe- 
bral fissures) is the third ocular sign of significance in exophthalmic 
goitre. Finally, Mobius calls attention to the frequency of insufficiency 
of the internal recti muscles. 

In addition to these characteristic symptoms loss of flesh and strength, 
moderate pyrexia of irregular type, impaired appetite, diarrhoea, and 
despondency are observed. The diarrhoea is of the nervous type — 
increased peristalsis without local catarrh. Menstruation is apt to be 
irregular or to cease. Tinnitus aurium, headache, and vertigo are not 



90 GENERAL DIAGNOSIS. 

uncommon, and sometimes there is profuse sweating. A restless, nervous 
excitement (Charcot) is very common. Muscular tremor (Marie), occur- 
ring on voluntary movement, is frequently observed, and, with diar- 
rhoea, is almost as common as the three primary symptoms. OEdema 
of the feet is often seen if there is coexisting mitral disease. Transitory 
vasomotor oedema of the eyelids, the face, hands, and the supraclav- 
icular and infraclavicular regions occurs. It is usually circumscribed, 
and may not pit on pressure. 

Fig " 




Exophthalmic goitre. 

Graves's disease, as a rule, runs a chronic course, lasting for years. 
A few cases that have run an acute course of a few weeks, some ending 
in recovery and some in death, have, however, been reported. More- 
over, there may be recurring attacks with apparent recovery in the 
inter yals. 

Death results from gradual weakening of the heart and its direct and 
indirect effects. It may be hastened also by uncontrollable diarrhoea, 
acute mania, and epilepsy. The disease may also be complicated with 
hemorrhages, and these may be the immediate cause of death. 

Enlargement of the thyroid gland from the above-mentioned causes 
must be distinguished from enlargement due to abscess, cancer, sarcoma, 
or adenoma. Abscess usually follows infectious diseases ; in the writer's 
case it followed typhoid fever. With carcinoma and sarcoma there is 
amemia and gradual loss of flesh. It must also be distinguished from 
other tumors in this region. It particularly must not be confounded 
with enlargement on the right side due to an innominate aneurism. 
(See Aneurism.) 

The Vessels of the Neck. Changes take place in the arteries and 
veins, observed by inspection, palpation, and auscultation. (For a de- 
scription of these changes, see Arteries and Veins.) 

The Lymphatic Glands. (See Chapter XI.) 



CHAPTER VIII. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 

THE EYE AND EAR. 

The Eye. Indirectly the eye and the skin are the external struc- 
tures that present the most evidence of disease in other organs. This 
is true of the eye, because of the comparative ease of its examina- 
tion, and because it is a highly specialized organ, bearing close relation- 
ship to the vascular and nervous system. Its special functions are 
subservient to the highest physiological cerebral action ; hence any per- 
turbation of or organic change in the cerebrum is expressed in altered 
eye function, either of movement or of vision. Its nerve and vascular 
connection with the brain render it sensitive to internal change. In 
diseases of the nervous system the eye is the one organ the examina- 
tion of which is essential to make a diagnosis. Constant reference in 
the chapter on Nervous Disease will be made to this section, and the 
converse holds that in the study of this section reference must be made 
to the nervous system. But diseases of the heart, the kidneys and sys- 
temic conditions, such as gout, rheumatism, diabetes, etc., find expres- 
sion often in some eye change. 

Much may be gained from an inspection of the eye and its adnexa 
regarding the state of the general system. This is at once evident 
when we reflect that of the twelve pairs of cranial nerves four pairs are 
devoted solely to this important organ, while in the eye itself we have 
unfolded to our gaze a living nerve-head, the optic papilla, and the 
retinal vessels, which offer to our view the perfect cycle of the supply 
of an organ with arterial and the escape of its venous blood. More- 
over, the eye presents in compact form representation of nearly all the 
tissues of the body. 

In order to insure that nothing shall escape scrutiny in the inspec- 
tion of the eye, it is necessary to follow some settled plan of investi- 
gation, and for this purpose it is well to pursue an anatomical order, 
proceeding from the superficial to the deeper structures. 

The Lids. (Edema is not an infrequent symptom of renal disease 
(see (Edema of the Face), and may occur in cases of profound anaemia 
and chlorosis ; it may indicate the prolonged use of arsenic, or it may 
be originated by disease of the orbit or some of the periorbital sinuses 
of the same side. The dropsy may accumulate during the night and 
be seen in the morning on rising. Morning puffiness is natural to 
some individuals. Both it and the swollen face following a debauch 
are not to be confounded with oedema. 

Ptosis, or drooping of the eyelid, may be congenital, more usually it 
is a symptom of disease within the brain. (See Paralysis of the Third 
Nerve.) 



92 GENERAL DIAGNOSIS. 

Lagophthalmus is that condition in which the lids can be closed 
but imperfectly, and follows paralysis of the orbicularis muscle, due to 
lesions of the portio dura. According to Bull and Hansen, paralysis 
of the orbicularis muscle is of common occurrence in leprosy. 

Blepharospasm, or active closure of the lids from spasm, is of a 
reflex nature, originated by excitation of a filament of the fifth nerve. 
It is always present to a greater or less degree in photophobia or intol- 
erance of light ; this latter symptom is a frequent associate of ocular 
disorders, and is also found in certain stages of meningitis, cerebral 
tumors, typhus, measles, etc. It accompanies many forms of head- 
ache, especially migraine, and it may be the expression of a hyper- 
esthesia of the retina in nervous subjects, apart from any actual in- 
flammation of the retina. Cramp of the orbicularis muscle has been 
noted quite often as a symptom of hysteria. Nictitation, or undue 
winking of the eyelids, occurs not infrequently in children as part of a 
habit of chorea. 

Styes or small boils which form on the tarsal margin, and blepharitis 
or inflammation of the. margin of the lids, while often due to an error 
of refraction, may denote some defect in the general health, such as 
anaemia or scrofula. 

Vaccinal eruption may appear on the eyelids, occurring as a 
small ulcer with an indurated border and yellow floor at the commis- 
sures, and is usually attended by some swelling of the lids and face 
and by enlargement of the preauricular glands. 

Chancre may appear either as a primary or secondary sore, and is 
generally situated in the conjunctiva lining the lids. 

Malignant pustule, or specific anthrax, is seen at times, though 
rarely, on the lids of those who are exposed to infection from diseased 
animals or decayed animal matter. 

Xanthelasma consists in the formation of small, irregular, opaque, 
yellowish patches, slightly elevated above the surrounding skin. These 
areas may either remain localized or the disease may involve the palms 
of the hands, the flexures of the fingers, and the inside of the mouth. 
(See Tongue.) 

The Orbit. Exophthalmus, or proptosis, abnormal prominence or 
protrusion of the eyeball, is usually occasioned by some disease of the 
orbit or of the neighboring sinuses which encroaches upon the cavity 
of the orbit. It is one of the diagnostic features of exophthalmic goitre 
(see Exophthalmic Goitre), and may also be caused by paralysis of the 
ocular muscles. It has been seen, though rarely, after spontaneous 
hemorrhages into the orbit in cases of haemophilia and scurvy. 

Enophthalmus, or retraction of the eyeball, may be the result of ex- 
hausting diseases, such as peritonitis, or secondary to some orbital 
lesion. It is very pronounced in the sudden atrophy that occurs in 
cholera from loss of water. 

Extraocular Muscles. Before detailing briefly the measures em- 
ployed for the detection of paralysis of the extraocular muscles, and 
that the subject may be grasped more readily, a few Avords of expla- 
nation will be given regarding the anatomy and physiology of the 
muscles engaged in the ocular movements. 



THE DATA OBTAINED BY OBSERVATION. 93 

The eyeball is suspended in the orbital cavity by means of six mus- 
cles — the four recti, superior, inferior, internal, and external, and the 
superior and inferior oblique. Of these the four recti and the superior 
oblique have their origin at the apex of the orbit, while the inferior 
oblique rises from its lower inner wall. These muscles exercise their 
action upon the movements of the globes in three pairs, each pair being 
composed of two antagonistic muscles ; the rectus internus and exter- 
nus ; the rectus superior and inferior, and the superior and inferior 
obliques. The sixth nerve supplies the external rectus, the fourth the 
superior oblique, the remaining four muscles receiving their impulses 
from the third nerve. 

When all of the muscles are in a state of equal tension and the visual 
axes are directed straightforward in the horizontal plane, the eyes are 
then said to be in the primary position. Any deviation from this is 
known as a secondary positio7i, the simplest of these being direct lateral 
or vertical movements. Thus, the rotation of the eye directly inward 
is accomplished by the rectus internus, outward by the rectus externus, 
upward by the superior rectus and the inferior oblique, and downward 
by the inferior rectus and the superior oblique. Oblique movements 
of the eyeball, however, are more complicated and necessitate the action 
of a third muscle to regulate the torsion which the eye undergoes Avhen 
it is moved from the perpendicular. This is occasioned by the fact 
that while the plane of the points of origin and insertion of the rectus 
externus and internus corresponds with the horizontal plane of the 
eyeball, that of the rectus superior and inferior and of the oblique mus- 
cles do not correspond with the vertical and horizontal planes respect- 
ively. Therefore, so soon as the globe is moved into the oblique posi- 
tion, it rotates or undergoes a certaion amount of torsion. Thus, the 
superior rectus, in addition to elevating the eye, rotates the upper part of 
the cornea toward the nose, while the inferior rectus, in direct antagonism 
to it, depresses the eye and rotates the upper half of the cornea exter- 
nally ; these muscles exercising their greatest degree of torsion when 
the eyeball is turned inward and either upward or downward. The 
superior oblique depresses the eye and rotates the upper part of the cornea 
internally, while the inferior oblique elevates the eye and rotates the 
upper half of the cornea externally. The obliques, in antagonism to 
the superior and inferior recti muscles, exercise their maximum amount 
•of torsion, therefore, when the eye is rotated externally and either 
upward or downward. 

It appears from the foregoing that in inward and downward 
motion the rectus internus and inferior and the superior oblique will 
be brought into play ; in outward and upward, the rectus externus 
and superior and the inferior oblique ; and in outward and down- 
ward movements the rectus externus and inferior and the superior 
oblique. 

Manner of Detecting Palsies of the Extraocular Muscles. 
Normally, the movements of both eyeballs are in perfect association 
and harmony, so that the images of objects fall upon corresponding 
points of both retinae, and single vision obtains. If this harmonious 
.action be interrupted by paralysis of one or more of the extraocular 



94 GENERAL DIAGNOSIS. 

muscles, however, then this no longer happens, and limitation in the 
movement and deviation of the affected eye is the result, coupled with 
double vision or diplopia. 

Limitation in the Movements and Deviation of the Af- 
fected Eye. In studying limitations of motion in the eyes, the ex- 
aminer seats himself before the patient and requests the latter to follow 
with his eyes the movements of a candle which is carried through all 
the different meridians of the visual fields, any muscular deviation 
being made evident by a failure in correspondence of the images from 
the candle reflected from the cornea, as well as by the lagging in the 
movements of the eye in the deviation of the action of the affected 
muscle. There are three general laws which have been formulated 
which should be borne in mind in this connection. 1. The limitation 
in motion as well as the diplopia increases toward the side of the 
affected muscle. 2. The secondary deviation (the deviation which the 
sound eye makes while the affected eye is fixing the candle) is greater 
than the primary deviation (the deviation of the affected eye while 
the sound eye fixes). 3. The image formed on the retina of the affected 
eye is projected in the direction of the paralyzed muscle. 

Diplopia. The character of the diplopia varies according to the 
muscle or muscles whose function has been disturbed. Generally 
speaking, diplopia is either simple or homonymous, or crossed or heter- 
onymous. In the former the image of the affected eye lies on the cor- 
responding side and betokens convergence of the visual axes, while in 
the latter the image of the affected eye is projected to the opposite side 
and indicates divergence of the visual axes. In order to ascertain the 
relation of the two images to the respective eyes, it is essential that the 
diplopia should be carefully tested. 

Test for Diplopia. For this purpose the patient is seated in a dark- 
ened room with a red glass placed before one of the eyes, in order to 
facilitate the identification of each image by its color, and a lighted 
candle is held on a level with the head about five metres off. Having 
noticed any deviation which the eyes make in the primary position, 
upon a chart especially constructed for this purpose, the candle is moved 
through the different meridians of the visual field, the patient being 
requested to regard the flame with both eyes while the head remains 
quiet, each deviation being carefully noted on the chart. 

After the deviations have been recorded the diagnosis of the affected 
muscle or group of muscles will be much facilitated by the following 
rules : If the diplopia be lateral, then the paralysis is either of the 
rectus internus or externus. If, in addition, the images are crossed, 
then the internus is at fault, but if they are homonymous the ex- 
ternus is paralyzed. If the diplopia be vertical, and in the upper 
field, then the paralysis is either of the rectus superior or the oblique 
inferior. If the images be crossed, paralysis of the superior rectus is 
indicated, but if they be homonymous, implication of the inferior 
oblique is designated. If the diplopia be vertical and in the lower 
field, then the paralysis is either of the rectus inferior or obliquus supe- 
rior — crossed images indicating paralysis of the rectus and homony- 
mous that of the oblique muscle. 



THE DATA OBTAINED BY OBSERVATION. 95 

Additional Symptoms. In addition to the study of the anomalies 
in motion and of the diplopia, considerable information may also often 
be gained by noting the position of the head in ocular paralyses. 
Thus, in paralysis of the sixth nerve, the face is turned toward the 
paralyzed side ; in paralysis of the fourth nerve, it is turned downward 
and toward the shoulder of the paralyzed side ; and in paralysis of the 
third nerve, the face looks toward the shoulder of the same side. Not 
rarely dizziness is complained of and false projection of the field of 
vision, causing patients to make faulty estimation of distance. 

The Clinical Significance of Disturbances in the Motility 
of the Extraocular Muscles. In addition to the significance 
which paralysis of the eye muscles bears io lesions of the brain and of 
the cranial nerves, and which will be dwelt upon at length later, dip- 
lopia may proceed from some much less serious disturbance, as, for 
example, derangements of the digestive organs or alcoholic intoxicants. 
Transient attacks of diplopia may be among the earliest symptoms of 
tabes dorsalis, and may occur at the very beginning of cerebral men- 
ingitis. 

Monocular diplopia is a rare symptom, and when it can be dis- 
associated from some local disturbance in the media of the eye, may 
be attributed to hysteria. 

Ocular deviations or paralytic squint, as has just been described, must 
be differentiated from concomitant squint or strabismus. In this latter 
variety there is no great restriction in movements of the eyes in any 
direction, the faulty position of the visual axis remaining constant 
while the eyes are moved from side to side, and the secondary devia- 
tion being equal to the primary. This is the condition which is com- 
monly known as cast or cross-eye, and usually makes its appearance 
in children with high degrees of far-sightedness. 

Nystagmus is a spasmodic condition of the muscles of the eye, pro- 
ducing rapid oscillations of the ball, usually horizontal, sometimes 
rotary and rarely vertical. It is of great value as a symptom, being 
found in many brain lesions, usually those of the restiform bodies, the 
vermiform process, and of the cerebellum. It is also seen in Fried- 
reich's ataxia, in miners, and often as the result of visual defects. 

Muscular Insufficiencies. Of late years much attention has 
been given by ophthalmologists and neurologists to the study of errors 
in the extraocular muscle balance in different reflex psychoses. While 
the assertion which has been made by some, that chorea and even epi- 
lepsy may be originated by such deviations, is extreme, it is neverthe- 
less quite true that many forms of headache, of vertigo, of nausea, and 
of vague neuralgic pain of a cephalgic type can be traced to this source. 
It is important, therefore, that the clinician should be acquainted with 
such errors, and should be familiar with the methods employed for their 
detection. 

The device of Maddox is usually employed for this purpose. This 
consists of a glass cylinder which is fitted into a linear opening, which 
is made in a metallic disk. The patient is seated before a candle flame 
five metres off and requested to regard the name with both eyes. The 
rod is then placed before one of the eyes perpendicularly and an image 



96 GENERAL DIAGNOSIS. 

of a perpendicular streak of light obtained from that eye. If the streak 
of light be deviated toward the same side as the eye before which it is 
held, a condition of excessive convergence or esophoria is present ; but 
if the streak deviates toward the opposite side, then a divergence of the 
visual axes or exophoria exists. If the streak be on a higher or lower 
level than the flame, vertical imbalance or hyperphoria is present. 
Balance of the muscles is known as orthophoria. 

The Conjunctiva. The conjunctiva being a transparent though 
vascular membrane, any changes in the amount or the constitution of 
the blood will at once evidence itself in its folds. Thus, in anaemia 
there is always a pallor of the conjunctival vessels, while in plethora 
there is usually a passive dilatation of the vessels which gives the eye 
an injected appearance, and occasions the " bloated eye " of the drunk- 
ard. In jaundice the conjunctiva is yellow. Spontaneous hemorrhages 
into the membrane are seen in whooping-cough, asthma, epilepsy, and 
in calcareous degeneration of the bloodvessels, and it may be the seat 
of hemorrhagic infarcts in ulcerative endocarditis. 

Inflammation of the conjunctiva is an early symptom in measles, and 
in typhus fever it is a constant sign, and serves to distinguish this affec- 
tion from typhoid. It is also present in yellow fever, and may likewise 
constitute one of the earliest signs of meningeal and cerebral diseases. 
A passive hyperemia follows disease of the cervical sympathetic. 

The Cornea. The cornea being an avascular membrane, deriving 
its nourishment from the surrounding structures, it is very prone to 
undergo inflammation whenever the vitality of the system becomes 
much lowered, and as a result of this inflammation opacities remain 
which have a very deleterious action upon vision. These opacities may 
be either superficial or interstitial. When superficial they are not infre- 
quently the result of burns, traumatisms, and extension of the inflam- 
mation from the surrounding conjunctiva ; in many cases they denote, 
however, that the eye has been the seat of a phlyctenular inflammation, 
a form of ocular disease which is quite common in scrofulous children 
and in individuals below par. 

Superficial ulceration of the cornea is observed also in all fevers of a 
typhoid type, when the patient lies in a semi-conscious state with the 
lids but partly closed. Dust and bacteria gather between the lids, 
and as the patient winks but seldom a crust forms on the cornea, which 
is followed by extensive ulceration. Abscesses of the cornea form in 
the stage of desquamation of variola, and must be differentiated from 
those which arise in the pustular variety of the disease at an earlier 
period. Ulcers also form in the seventh week of typhoid, being usually 
coincident with abscesses in the scalp and skin of the back. 

The type of interstitial opacities of the cornea is seen in inherited 
syphilis. Indeed, to the trained eye, the appearance of the haze in 
this class of cases is so characteristic that the diagnosis of the systemic 
affection might be made for the eye alone. Malaria and scrofula may 
also produce similar types of corneal inflammation. The small areas 
of opacity which form in the upper and lower parts of the cornea near 
the limbus, and which at times encircle the cornea, are known as arcus 
senilis. This is commonly supposed to be indicative of arterial sclero- 



THE DATA OBTAINED BY OBSERVATION. 97 

sis, although the author has never found ground to warrant this asser- 
tion. It may always be diagnosed from a somewhat similar opacity of 
inflammatory origin by the fact that in the latter variety, the opacity 
being due to an inflammation usually beginning at the corneo-scleral 
margin, the haze is continuous with the conjunction of the two mem- 
branes ; whilst in arcus senilis there is a zone of clear corneal tissue 
between the margin of the cornea and the rim of the opacity. 

After lesions of the fifth nerve the cornea may ulcerate from trau- 
matic and trophic causes, and after paralysis of the seventh nerve it 
may suffer from exposure due to inability to close the lids. 

Iris. Inflammation of the iris is a common symptom of secondary 
syphilis ; it occurs under the form of a gummatous infiltration of the 
membrane in the tertiary variety, and is seen, though rarely, in inher- 
ited syphilis. It is not an infrequent symptom of chronic rheumatism 
and gout, and may be caused by tuberculosis and rheumatoid arthritis. 

The Pupil. The pupil may react either directly or indirectly to 
light stimulus. In order to observe this, the patient is seated before a 
window and requested to gaze at the sky. The examiner, stationed in 
front of the patient with his back to the window, excludes one eye by 
placing his hand over it, and notes the size of the pupil under diffuse 
daylight. The eye is then covered with the other hand, and the dila- 
tation which should follow is also approximated. The hand is then 
withdrawn, and, if nothing prevents, the iris will contract to the same 
size as that which existed at the commencement of the test. The 
fellow eye is then to be tried in a similar manner. This is known as 
the direct reflex action of the pupil ; indirect or consensual reflex action 
being the contraction or dilatation which occurs in the shaded eye when 
the exposed eye is being examined, and should correspond precisely 
with the movements of the pupil of that eye. 

Having noted the reaction of the iricles to light stimulus, the patient 
is now directed to transfer his gaze to the examiner's finger, which 
should be made to slowly approach the eye, whilst its fellow is screened 
off as in the former test. The amount of the contraction induced by 
this accommodative effort is carefully noted, and the same procedure 
repeated in the fellow eye. The obstructing hand is finally removed, 
and the patient being requested to look fixedly at the tip of the sur- 
geon's finger with both eyes, observation is made of the contraction of 
the pupil, which should be induced by the effort at convergence which 
is occasioned by approximating the finger to the eyes in the median 
line. 

Hippus is a spasmodic alternating contraction and dilatation of the 
pupil, which is seen at times in mania, hysteria, and other allied disor- 
ders. Rhythmical alterations in the size of the pupils occur frequently 
in the so-called Cheyne-Stokes respiration ; the pupil contracting 
during the period of apnoea and dilating with the first few breaths. 

Modification in the Size and Behavior of the Pupils as 
the Result of Disease. Pupillary reaction to light is a reflex phe- 
nomenon, the optic nerve being the afferent nerve, and the third nerve 
the efferent nerve, supplying the sphincter of the iris ; communicating 
fibres between the corpora quadrigemina and the centre from the third 



98 GENERAL DIAGNOSIS. 

nerve making such a reflex possible. The mechanism of pupillary 
reaction being of an extremely complicated nature, and necessitating 
the activity of a number of nerves and nuclei, it is not strange that 
anomalies in its behavior should be frequently met with in disorders 
of the central nervous system. 

Dilatation of the pupil (mydriasis), apart from local diseases, of 
which glaucoma is the type, may be produced by certain psychical 
emotions, such as fright and emotion, or it may be caused by diseased 
processes giving rise to irritation of the pupil — dilating centre or fibres 
(irritative or spasmodic mydriasis), or by paralysis of the pupil — con- 
tracting centre or fibres (paralytic mydriasis or iridoplegia). 

Irritation mydriasis occurs (a) in hyperemia of the cervical portion 
of the spinal cord and in spinal meningitis ; (b) in the early stages of 
new growths in the cervical portion of the cord ; (c) in cases of intra- 
cranial tumor and other diseases causing high intracranial pressure, 
according to Raehlmann, although Leeser points out that these may 
also give rise to paralytic mydriasis ; (d) in the spinal irritation of 
chlorotic or anaemic people, after severe illness, etc. ; (e) as a premoni- 
tory sign of tabes dorsalis ; (/) in cases of intestinal worms, owing to 
the stimulation of the sensitive nerves of the bowel, and sometimes in 
other forms of intestinal irritation ; (g) in psychical excitement — e. g., 
acute mania, melancholia, progressive paralysis of the insane (often, 
then, unilateral, with myosis in the other eye). (After Swanzy.) 

Paralytic mydriasis (iridoplegia) may be due either to a paralysis of 
the pupil contracting centre or as a result of the stimulus not being 
conducted from the retina to that centre. It may be found under the 
former circumstances : (a) Sometimes in progressive paralysis where 
at first there was myosis ; (b) in various diseased processes at the base 
of the brain affecting the centre of the third nerve ; (c) in a late stage 
of thrombosis of the cavernous sinus ; (d) in orbital processes which 
cause pressure on the ciliary nerves. (After Swanzy.) 

It is said to be present in acute dementia, when there is oedema of 
the cortex, and is found in cerebral softening. It occurs in irritation 
of the cervical sympathetic and occasionally in aortic insufficiency. 

Contraction of the Pupil (Myosis). Having excluded myosis 
from local causes, especially from the sequelse of iritis, it will be found 
that contraction of the pupil may be caused by a disease process irri- 
tating the pupil-contracting centre or nerve-fibres (the irritative myosis 
of Leeser), or by one causing paralysis of the pupil-dilating centre 
or nerve-fibres (the paralytic myosis of Leeser), or by a combination 
of both. 

Irritation myosis is found in (a) the early stages at least of all in- 
flammatory affection of the brain and its meninges, in simple, tuber- 
cular, and cerebro-spinal meningitis. When, in these diseases, the 
medium myosis gives place to mydriasis, the change is a serious prog- 
nostic sign, indicating the stage of depression with paralysis of the 
third nerve ; (b) in cerebral apoplexy the pupil is at first contracted, 
according to Berthold, who points out that this contraction is a diag- 
nostic sign between apoplexy and embolism, in which latter the pupil 
is unaltered ; (c) in the early stages of intracranial tumors situated at 



THE DA TA OB TA INED B Y OB SEE VA TION. 9 9 

the origin of the third nerve or in its course ; (d) at the beginning of 
a hysterical or of an epileptic attack ; (e) in tobacco amblyopia, prob- 
ably from stimulation of the pupil-contracting centre by the nicotine ; 
(/) in persons following certain trades, as the result of long main- 
tained effort of accommodation (watchmakers, jewelers, etc.), the pupil- 
contracting centre being subject to an almost constant stimulus ; (g) as 
a reflex action in ciliary neurosis ; consequently, in many diseased con- 
ditions of those parts of the eye supplied by the fifth nerve. (After 
Swanzy.) 

Paralytic myosis occurs in spinal lesions above the dorsal vertebra — 
e. g., injuries and inflammations, especially of the chronic form. The 
contracted pupil occurring in gray degeneration of the posterior columns 
of the spinal cord has been long known as spinal myosis. In the 
simple form of this myosis the pupil has but a medium contraction, 
and reacts both to light and on convergence. This condition is found 
in the early stages alone, when the disease has attacked merely the 
cilio-spinal centre, or higher up, as far as the medulla oblongata ; later 
on, when Meynert's fibres become engaged, we have the Argyll-Rob- 
ertson pupil. The very minute pupil often seen in tabes dorsalis is 
probably due to secondary contraction of the sphincter pupillse. 

Paralytic myosis is also found in general paralysis of the insane. In 
acute mania the pupil is usually much dilated, and when this mydriasis 
is changed for myosis approaching general paralysis may be prognosti- 
cated. Myosis, following on irritation mydriasis, is also found in mye- 
litis of the cervical portion of the cord. In bulbar paralysis, if paralytic 
myosis occurs, the disease is probably complicated with progressive 
muscular atrophy, or with sclerosis of the brain and spinal cord. 
Myosis may also be due to paralysis of the cervical sympathetic, result- 
ing from injury, from pressure of an aneurism of the carotid, innomi- 
nate, or aorta, or from pressure of enlarged lymphatic glands. In 
apoplexy of the pons varolii myosis is present, but it is not yet certain 
whether it is an irritation myosis or a paralytic myosis. 

Inequality of the pupils may denote lesion of the third nerve, affection 
of the cervical sympathetic in the cervical region of the spinal cord, 
general paralysis of the insane, or some unilateral lesion of the brain. 

The Lens. Cataract. An opacity in the crystalline lens should 
always awaken the suspicion of its being due to diabetes, as cataract is 
of not infrequent occurrence in this disease. Although renal disease 
also has been held accountable by some for the occurrence of cataract, 
no satisfactory evidence has been given to prove this assertion. 

The Eye Ground. In order to study the remaining structures of 
the eye, it is necessary to have recourse to the ophthalmoscope. The 
essential part of this instrument consists in a concave mirror, whereby 
the light from a lamp which is placed back and slightly to the side of 
the patient's head may be projected into the interior of the eye about 
to be examined. This mirror is provided with a small central aper- 
ture, through which the examiner looks and studies the details of the 
back of the eye or fundus oculi, as it is technically called. When the 
instrument is held close to the eye, and the eye-ground studied without 
the intermediation of other means, the procedure is known as the direct 



100 GENERAL DIAGNOSIS. 

method of ophthalraoscopical examination. In the indirect method, on 
the other hand, the ophthalmoscope is held about sixteen inches from 
the eye and an inverted image of the fundus obtained by means of a 
convex lens, which is interposed between the ophthalmoscope and the 
eye, and serves to collect the rays of light into a focus between the lens 
and the eye of the examiner. The former method possesses the advan- 
tage of magnifying the interior of the eye about fourteen times, while 
the indirect, although of less magnifying power, permits of the exami- 
nation of a greater part of the fundus at a glance. 

The ophthalmoscope, in addition to giving us information in regard 
to the condition of the media of the eye, as, for example, of the exist- 
ence of commencing cataracts, or of opacities within the vitreous humor, 
unfolds to our gaze the head of the optic nerve as well as the retina 
and the choroid, and renders patent to our view the different diseases to 
which they are liable. 1 

Retinitis. The systemic affection which is accompanied by a lesion 
of the retina more often than any other is disease of the kidneys, espe- 
cially chronic interstitial nephritis. Indeed, about 30 per cent, of all 
cases of this variety of renal lesion have an ocular manifestation. Ret- 
initis may also be seen as an early symptom in the nephritis of scarlet 
fever and pregnancy. Its occurrence in the cirrhotic kidney is of 
gloomy import, for patients with a retinal complication in this disease 
usually die within two years of its first appearance. Retinitis may also 
be occasioned by pernicious anaemia, leukaemia, diabetes, syphilis, and 
heart disease. 

Choroiditis is usually the result of syphilis, but may in rare in- 
stances be the seat of tubercles. Gout may also originate a subacute 
inflammation of the membrane. 

Optic Neuritis. The optic nerve being really a prolongation of 
the brain, and being, of a consequence, so often liable to be affected in 
cerebral disorders, it is of the utmost importance that the clinician 
should be able to recognize changes in its appearance. Indeed, it is 
safe to say that the study of a " nervous case/' so called, is never com- 
plete without the report of the ophthalmoscopic findings. 

Papillitis, or choked disk, an inflammation of the head of the optic 
nerve, is rarely idiopathic, but is occasioned by cerebral growths and 
by meningitis, especially of the base of the brain, and by the same con- 
stitutional diseases which originate retinitis. It also occurs in acute 
fevers, and it may be the result of suppression of the menstruation. 
Usually, however, choked disk is the result of an intracranial tumor, 
occurring in 90 per cent, of all such cases, and as it is an early sign, its 
detection has frequently been the means of the discovery of many in- 
tracranial neoplasms. As a rule, tumors of the cerebellum and those 
of the cerebrum which interfere with the circulation in the lymph pas- 
sages of the brain originate it, the size and the character of the tumor 
not seemingly influencing its production. 

The variety of optic neuritis which has just been discussed is an 

1 It has not been thought proper in a work of this kind to give further details re- 
garding ophthalmoscopy, the student being referred to special text-books upon ophthal- 
mology for a perusal of that important subject. 



THE DATA OBTAINED BY OBSERVATION. 101 

ascending neuritis, the inflammation beginning at the intraocular termi- 
nation of the nerve and spreading upward from this to the brain. 
There is also an interstitial or descending neuritis which is commonly 
caused by meningitis. Retrobulbar or toxic neuritis is a variety of 
Inflammation of the optic nerve where the disease confines itself to the 
bundle of nerve-fibres which go to supply the macular regions. This 
disease is commonly caused by alcohol and tobacco, although it may be 
originated by quinine, the salicylates, lead, and iodoform. It may also 
be caused by rheumatism and catching cold, and there is a rare form 
where the disease is transmitted through certain families from genera- 
tion to generation. 

Optic Atrophy. This may be secondary to some inflammation of the 
optic nerve or retina, or it may be a primary disease. 

Secondary or consecutive atrophy is usually the result of optic neu- 
ritis ; it may, however, be originated by local causes either within the 
eye or the orbit. Primary atrophy, on the other hand, though occa- 
sionally idiopathic, is generally found associated with some disease of 
the spinal cord, especially with locomotor ataxia. In this affection it 
is frequently an early sign, and it has been noted by Benedikt, of 
Vienna, that when this occurs it is rare for a tabetic patient to become 
ataxic. It has also been remarked that cases in which blindness is 
well advanced suffer but little from the pains which are characteristic 
of this disease. Simple atrophy occurs also in lateral and insular 
sclerosis, and is frequently seen in general paralysis of the insane. 

Before proceeding further with the consideration of the cerebral 
expansion of the optic nerve, it becomes necessary to study the methods 
which are used in the determination of the visual acuity, both central 
and peripheral, as these are valuable and often necessary adjuncts in 
establishing the diagnosis of many obscure, cases of cerebral disease. 

Central vision is tested by means of black letters printed on a 
white test card, those devised by Snellen being usually employed on 
account of the admirable system upon which they are founded. The 
patient is seated five metres away from the card, and one eye being blind- 
folded he is requested to read the lowest line of letters which he can 
distinguish. If the vision fails to correspond to the standard, it is 
necessary to exclude hypermetropia, myopia, and astigmatism by means 
of convex, concave, and cylindrical lenses before it can be definitely 
asserted that the vision is lowered as the result of disease. 

Peripheral vision, or the extent of space of which the eye is con- 
scious when it is fixed on any given point, may be estimated in several 
ways ; it is accomplished, however, most accurately by means of the 
perimeter. This is an instrument which consists of an upright rest 
for the chin and a semi-circular arc or bar, graded in degrees, which re- 
volves upon a middle point, and is capable of describing a hemisphere 
in space. The eye under examination being directed straight ahead at 
the fixation point, the fellow eye being blindfolded, the test object, a 
small square of white paper, is brought from the periphery toward 
fixation. The patient is then asked to indicate the instant the object 
is perceived, and the examiner marks the degree upon a chart pro- 
vided for the purpose. If the perimeter be not at hand, the field 



102 



GENERAL DIAGNOSIS. 



may be obtained fairly accurately as follows : The patient is seated 
opposite the surgeon with one eye bandaged. He is then directed to 
look at the corresponding eye of the examiner whilst the observer's 
finger is slowly brought in from the periphery toward the eye through 
the different meridians. In this way the surgeon can ascertain whether 



Fig. 11. 




The McHardy perimeter. 

the patient permits his eye to wander from the fixation point, and at 
the same time he can compare the extent of the patient's field with 
that of his own. The field for form or white extends over 150° 
horizontally and 110° vertically, that of the different colors falling 
within this in the following order — yelloAV, blue, red, and green. 

Scotoma. As the patient's macula corresponds to the fixation point 
in the visual field, the physiological blind spot which is occasioned by 
the entrance of the optic nerve into the eye will be found in the tem- 
poral portion of the field. Pathological blind spots are knoAvn as 
scotoma, and these may be either central, paracentral, or disseminated. 
When central, they indicate either a disease of the macula or of the 
fibres of the optic nerves supplying the macula, so that a central 
scotoma is one of the diagnostic features of retrobulbar neuritis. 

Hemianopsia. This term is used to imply a defect in one-half 
the field of vision, the defect being named according to the blind area. 
Thus, temporal hemianopsia means that the eye cannot perceive objects 
when situated in the outer half of the field. The most common form 



PLATE I. 



LEFT VISUAL FIELD. RIGHT VISUAL FIELD. 
Fixation Point. Fixation Point. 




I. Genicu/ate Body 
Lint Capsule 



rc '/»'ffr/ Cortex 



R. OmpiW 



THE DATA OBTAINED BY OBSERVATION. 103 

of hemianopsia is the loss of the temporal field in one eye and of the 
nasal field in the other, this condition being known as lateral homony- 
mous hemianopsia. If the temporal portions of both fields are lost, 
the defect is known as bitemporal hemianopsia ; binasal hemianopsia, 
indicating a loss in the nasal fields of both eyes. Superior and inferior 
hemianopsia are very rare. 

It is often possible bi/ studying the changes in the visual fields to locate 
quite definitely the seed of the cerebral lesion. By a reference to the 
diagram (Fig. 12) it will be at once evident that a lesion of the 




l f % R 

Diagram showing the course of the optic fibres in the chiasm. (Hirt.) 

chiasm would necessarily comprise the crossed fibres of the optic nerve, 
and would occasion bitemporal hemianopsia. Such a lesion may be due 
to basilar meningitis, periostitis, liyperostitis, fracture of the body of 
the sphenoid, distentions of the infundibulum, and of the third ven- 
tricle, or to tumors, especially those of the pituitary body, and finally 
syphilitic gumma. If due to the latter cause, there may be transient 
recurrent attacks of the hemianopsia. Bitemporal hemianopsia is also 
an early symptom of acromegalia. The lesion in superior and inferior 
hemianopsia is usually in the chiasm also, affecting its superior or in- 
ferior portions ; these defects in the fields may, however, be caused by 
symmetrical cortical lesions and by optic neuritis. (See Plate I.) 

If the lesion affects the outer angle of the chiasm, then monocular 
nasal hemianopsia is the result. 

Lesioxs of the Teact and Cextres. As shown in Plate I., 
the optic tract after crossing the eras to the hinder part of the optic 
thalamus divides into two branches, one going to the thalamus and the 
external geniculate bodies and to the anterior quadrigeminal bodies 
from which fibres pass into the hinder part of the internal capsule, and 
entering the occipital lobe, form the fibres of the optic radiations termi- 
nating in the cuneus, the perceptive visual centres ; while the fibres of 
the other branch pass to the internal geniculate bodies and the posterior 
quadrigeminal bodies. 

A lesion affecting the optic fibres anywhere posterior to the optic 
chiasm will produce lateral hemianopsia, so that this symptom of itself 
is of little value in localizations. There are, however, certain accessory 
symptoms which, when taken in conjunction with it, will often serve to 
establish the seat of the lesion in most instances. Thus, in hemian- 
opsia from lesions of the optic tract there is an absence of the symptoms 
which occur when the cortex is affected — as mind-blindness, word- 



104 GENERAL DIAGNOSIS. 

blindness, etc. — while other symptoms indicating a basal lesion are apt 
to be present, as, for example, implication of the cranial nerves, espe- 
cially those supplying the ocular muscles. Lesions of the optic tract 
are also frequently associated with a disease of the eras cerebri, so that 
hemianesthesia or hemiplegia of the opposite side of the body would 
be associated with the hemianopsia. There is, however, a sign which 
enables us at once to say definitely whether the lesion be in the optic 
tract or not, and this is known as the Wernicke or pupillary inaction 
sign. This is elicited as follows : The patient is seated in a darkened 
room with one eye blindfolded, and is directed to look straight ahead 
into the darkness. The eye being slightly illuminated by an assistant 
by means of the diffuse light from a plane mirror, which is reflected 
into the eye from a light placed behind the patient's head, the examiner 
slowly throws a small beam of concentrated light from a concave mirror 
upon the blind half of the retina. If the pupil fails to react, the lesion 
is then in the geniculate bodies or in the tract, inasmuch as the failure 
in the pupillary activity indicates that the lesion must have involved 
the sensory motor arc of the pupil as well as the visual fibres. 
Although when present the Wernicke sign is of great value, recent 
observations have shown that its absence is not conclusive. Lesions 
of the optic tract may be due either to neoplasms or to tubercular or 
gummatous meningitis, or more rarely they may be the result of cere- 
bral softening and hemorrhage. As yet clinical evidence is too meagre 
to permit of a diagnosis of lesions of the primary optic ganglia (pulvi- 
nar anterior corpora quadrigemina and external geniculate bodies), 
although in lesions of the pulvinar two typical symptoms occur — viz., 
hemianopsia and athetosis — and sometimes hemianesthesia may be 
present. In like manner, also, while it is generally believed that 
lesions of the optic radiations cause homonymous hemianopsia, it has 
not been definitely proven that these fibres have solely to do with 
vision. 

The hemianopsia is usually thought to depend upon cortical lesions 
in the occipital lobe, when it is unaccompanied by any of the accessory 
symptoms which have just been detailed. The chief diagnostic symp- 
tom of a central lesion, however, is what is designated as negative 
vision, " vision nulle," for in these cases the patient has no subjective 
sensations of the defect in his visual field. Cortical hemianopsia may 
also be incomplete, but a quadrant of the field being lost. 

Transitory hemianopsia, or scintillating scotoma, is the occurrence of 
symmetrical defects in the field of vision which usually conform to the 
hemianopic type, and in which a play of lights frequently appears as a 
precursor of an attack of migraine. (See Migraine.) 

Visual hallucinations may also be hemianopic in character, and are 
due to irritation of the visual memory centre. 

Hysterical amblyopia may manifest itself either in complete blindness 
or central scotoma, but more commonly as defective central vision with 
concentric contraction and reversal of the visual fields. 

Paralysis of the Motor Nerves of the Eyeball. Although in the 
section which dealt with the diseases of the ocular muscles the vari- 
ous forms of ocular deviation and the different varieties of diplopia 



THE DATA OBTAINED BY OBSERVATION. 105 

which resulted therefrom were mentioned at length, it is necessary to 
refer still further to their causes and to point out their connection with 
cerebral diseases. 

Paralysis of the orbital muscles may be due to orbital lesions or to 
those at the base of the brain ; they may indicate pontine lesions, or 
they may be originated by causes operating higher up in the cerebrum 
above the nuclei. In making the differential diagnosis between central 
and peripheral palsies, it must be remembered that those of central 
origin are frequently associated with other symptoms which denote 
intracranial involvement, while peripheral palsies are generally isolated 
and often complete. 

Peripheral paralyses of the orbital muscles are generally the 
result of either rheumatism or syphilis. When due to the latter 
disease they are usually tertiary manifestations, and especially is this 
apt to be the case if the third nerve is involved, which seems to be 
singularly prone to be attacked by gumma of the base. Paralysis of 
the sixth nerve is frequently of rheumatic origin. 

Syphilis causes fully one-half the cases of central paralysis, affecting 
either the nuclei of the nerves or the neighboring brain structure, the 
third and fourth ventricles, or the aqueduct of Sylvius. 

Diphtheria usually causes a paralysis of the ciliary muscle ; it may, 
however, affect one or more of the external muscles. Diabetes is com- 
plicated at times by paralysis of the external rectus. Influenza, herpes 
zoster, and whooping-cough are also rare causes of ocular palsies. 
Paralysis of the eye muscles is seen in paretic dementia, bulbar paraly- 
sis, and in multiple and posterior sclerosis. In locomotor ataxia they 
may be transient and appear at an early stage of the disease. Ocular 
palsies have also been caused by poisoning by lead, nicotine, sulphuric 
acid, carbonic oxide, and tainted meat. 

Complete paralysis of the third nerve causes the following 
symptoms : The upper lid droops, the pupil is partially dilated and 
immovable, and the power of accommodation is lost. The globe is 
slightly protruded and strongly diverged externally by the two unaf- 
fected muscles (the external rectus and the superior oblique). In in- 
complete paralysis of the third nerve, as well as in paralysis of the fourth 
and sixth nerves, the diagnosis is made by a study of the deviations and 
by the character of the diplopia, which has been already referred to. 

There is a peculiar form of intermitting paralysis of the third nerve, 
known as ophthalmoplegic migraine, which occurs in the young and is 
associated with headache and at times with vomiting. 

Paralysis of the ciliary muscle, or cycloplegia, follows a lesion of the 
trunk of the oculomotor nerve or of the anterior part of its nucleus. 
It is quite common as a sequel of diphtheria, and occurs, though rarely, 
in connection with spinal disease. 

Ophthalmoplegia externa and interna refer to paralyses of all or nearly 
all of the external and internal muscles. As the lesion in this affec- 
tion is central, it is frequently known also as nuclear paralysis. In its 
acute form it is due either to an acute inflammatory process in the 
nuclei or to hemorrhage, while the chronic depends upon a degenerate 
atrophy of the nerve nuclei, similar to that which is seen in progressive 



106 GENERAL DIAGNOSIS. 

muscular atrophy and in chronic bulbar paralysis, with which they 
may become associated. 

In conjugate lateral deviations of the eyes, although the axes of vision 
of both eyes are deviated from the middle line, yet they remain parallel 
with one another. This condition is generally the result of a cortical 
lesion which involves the movements of the eyes to the right or to the 
left, and is usually the result of apoplexy. A spasm deviation of the 
eyes in the same direction occurs as the result of irritative lesions of the 
brain, involving the association centres or tracts, and also in hysteria. 

The Localizing Value of Paralysis of the Orbital Muscles.' 

Paralysis of the Third Nerve. Ptosis, the most frequent symptom 
of diseases of this nerve, may be present as a focal symptom in cortical 
lesions without paralysis of any other branch of the third nerve. This 
would seem to indicate a special centre for the elevator of the lids, and 
though not definitely ascertained, such a centre is believed to exist in 
front of the upper extremity of the ascending frontal convolution close 
to the centre. Ptosis on the side of the lesion, without paralysis of the 
other branches of the third nerve, has been seen in disease of the pons, 
and again by forming a factor of a crossed paralysis may seem to 
localize a lesion in the crus cerebri, although Avhen the third nerve is 
paralyzed by a lesion in this situation it is usually involved as a whole. 

Grossed hemiplegia is a term used to express a disease of the crus 
cerebri when there is paralysis of the third nerve on the side of the 
lesion, with hemiplegia, hemianesthesia, and often facial and sometimes 
hypoglossal paralysis of the opposite side of the body. 

Complete paralysis of every branch of the third nerve without any 
other paralysis is almost always basal ; so, also, are those cases in 
which when there is hemiplegia it is slight as compared with the degree 
of the third-nerve paralysis. Lesion of the interpeduncular space and 
thrombosis of the cavernous sinus also indicate third-nerve palsies ; but 
in the latter the other orbital nerves, as well as the fifth and the optic 
nerve, may be involved as well Third-nerve symptoms may also be 
distant symptoms of tumors of the cerebral hemispheres, more particu- 
larly if accompanied by violent general head symptoms. 

As a symptom of cerebral lesion solitary paralysis of the fourth nerve 
is rare. When present it is apt to be produced by a basal lesion. In 
combination with paralysis of the third nerve it speaks for a lesion in 
the cerebral peduncle extending back to the valve of Vieussens. 

When j^ctralysis of the sixth nerve occurs as the only focal sign it is 
probably due to disease of the base as a distinct symptom. On account 
of the lengthened course these nerves take over the most prominent 
part of the pons, which renders them readily affected by distant press- 
ure ; they are more liable to provide a distant symptom than any other 
cranial nerve. Thus paralysis of this nerve is not infrequently a dis- 
tant symptom of tumor of the cerebellum, whereas paralysis of the 

1 This section has been epitomized from the excellent article on the subject in 
Swanzy's Hand Book of Diseases of the Eye. 



THE DATA OBTAINED BY OBSERVATION. 107 

third nerve is more apt to be a distant symptom in a lesion of the cere- 
bral hemisphere. 

Paralysis of the sixth nerve, simultaneous in its onset with hemi- 
plegia of the opposite side of the body, indicates a lesion in the pons, 
usually a hemorrhage, on the side corresponding to the paralyzed nerve. 
Basal paralysis of the nerve is frequently double, especially in syphilis. 
In combination with paralysis of the facial, paralysis of the sixth 
nerve is referable to a pontine lesion. 

The Ear. 

Subjective Symptoms. Buzzing, roaring, hissing, singing, and 
other sounds in the ear — tinnitus aurium — are symptoms which may 
or may not be due to disease of the ear. If associated with vertigo, it 
may be due to Meniere' 's disease. They may be the aura preceding an 
epileptic attack or the subjective phenomena attending syncope. Many 
drugs when pushed to physiological effects cause tinnitus. 

The External Ear. The external ear should always be examined. 
The thin ear may show the ansemic or chlorotic hue more strikingly 
than other portions of the body, or the opposite condition may be 
more vividly shown. Hmmatoma auris is seen in general paralysis of 
the insane and in other forms of insanity. It is a trophoneurosis. 
The ear is thickened and deformed, on account of effusion of blood 
between the cartilages and the perichondrium. It is discolored, and 
simulates the subcutaneous effusion due to injury. Tophi are observed 
in the external ears of patients with a gouty diathesis. They are 
small, hard, gritty accretions, seen in the external ear along the margin 
or in the depressions. They consist of urate of soda. 

The Discharge. When cerebral symptoms or symptoms of infec- 
tion (pyaemia) are present the presence or absence of ear discharge must 
be ascertained. Middle-ear disease very frequently results in inflam- 
mation of the mastoid, and from thence the sinuses and adjacent mem- 
branes of the brain become inflamed ; or the ear suppuration may be 
the primary focus from which general infection has taken place. It 
may not be possible in all cases to observe a discharge. It may have 
diminished or disappeared on account of the fever. Tenderness and 
oedema over the mastoid, perforation or bulging of the ear-drum, as 
well as other inflammatory signs, point to the occurrence of suppura- 
tion of the middle ear and mastoid cells. It must not be forgotten 
that a bloody discharge from the ear may take place in fractures of the 
skull. The ears must also be examined in cases of coma from injury, 
or if the origin of coma is obscure. 

The Auditory Nerve. The Hearing. The power and acuteness of 
hearing must be tested. This may be done with the voice, a watch, or 
a tuning-fork. Normally, the instrument should be heard at an equal 
distance from either ear. If both sides are equally affected the hear- 
ing of a patient must be compared with that of a healthy person. The 
ticking of a watch should be heard at a distance of about three feet. 
The tuning-fork is used by placing it on the skull. In some cases the 
voice may be easily heard, while the ticking of a watch can be distin- 



108 GENERAL DIAGNOSIS. 

guished only with great difficulty. The tuning-fork is used to deter- 
mine by bone conduction whether deafness is due to obstruction or 
disease of the auditory nerve. If it is due to obstruction the vibrating 
tuning fork placed on the vortex is heard better on the deaf side on 
contact with the skull than when held close to the ear (Rhine's test). 
Obstructive deafness, is always due to disease of (1) the external meatus, 
(2) the tympanic membrane and middle ear, or (3) the Eustachian tube. 

Deafness from internal ear disease may be due to affections of the 
labyrinth — as inflammation, caries, and necrosis— or of the auditory 
nerve. The tuning-fork is not heard on contact with the skull. The 
auditory nerve may be diseased in its course, or the auditory centre 
may be affected. (See Nervous Diseases, Part II., Chapter VIII.) 

It must not be forgotten that certain drugs, as quinine and the sali- 
cylates, may cause deafness. It may be an early and premonitory 
symptom of typhoid fever, or cerebro-spinal meningitis, and may occur 
early or late in the course of mumps. Deafness due to occupation is 
worthy of mention. It is not uncommon in blacksmiths, boiler-makers, 
locomotive engineers, and firemen. In some instances the patients can 
hear better in the noise incident to their work than when the surround- 
ings are absolutely quiet. 

Hyperesthesia of the Auditory Nerve. Very rarely in cer- 
tain cases of facial paralysis, and not seldom in hysteria, there is abnor- 
mal acuteness of hearing (oxyacoia). In some individuals suffering 
from hemicrania or tic douloureux, and in meningitis, the hearing of 
certain sounds — for example, high musical notes and whistling — is 
accompanied by pain. Nervous patients often complain of subjective 
noises, buzzing, roaring, hissing, and singing — the so-called tinnitus 
aurium. 

Paralysis of the Auditory Nerve. No case of absolute uni- 
lateral deafness, due to a focal lesion in a hemisphere, has as yet been 
observed. Deafness from disease of the auditory nucleus is very rare. 
That due to disease of the peripheral nerve is much more common. 
We may have a rheumatic auditory paralysis similar to that of the 
facial nerve, or the deafness may be due to pressure from a tumor or 
inflammatory exudate at the base of the brain, or disease of the mas- 
toid process of the temporal bone. The localization of the lesion is 
often extremely difficult. The only positive point is, that labyrinthine 
disease is apt to be accompanied by vertigo while in disease of the 
nerve-trunk vertigo is absent. 

Meniere's Disease. Aural Vertigo. We may define vertigo as a 
subjective feeling of motion referred by the patient either to his own 
body or to surrounding objects, with loss of equilibrium and without 
unconsciousness. 

In this disease, first described by P. Meniere in 1861, there is 
paroxysmal vertigo (sometimes so sudden and intense as to throw the 
patient to the ground), tinnitus aurium, nausea, pallor, clammy sweat, 
and vomiting. The severity of the attacks varies greatly. There may 
be momentary unconsciousness. There is sometimes jerking of the 
eyeballs, nystagmus, or diplopia. The disease is paroxysmal in char- 
acter, but slight vertigo and tinnitus are apt to persist between the 



THE DATA OBTAINED BY OBSERVATION. 109 

attacks. Some deafness is present. The attacks may vary in frequency 
from several in a day to only one in several months. 

Paralyzing Vertigo. Gerlier describes a remarkable form of parox- 
ysmal vertigo accompanied by weakness, paresis in the extremities, 
drooping of the eyelids, marked lassitude, and depression without un- 
consciousness. It occurs only in men, and is epidemic in the Canton 
of Geneva. 

Hysterical or functional deafness is recognized by (1) its association 
with undoubted symptoms of hysteria ; (2) its sudden occurrence 
after shock, emotional disturbance, or trauma ; (3) the absence of a 
cause in the auditory apparatus for the deafness ; (4) impairment of 
bone-conduction and aerial conduction to the same degree ; (5) the 
frequent coexistence of anaesthesia of the pinna and external meatus ; 
(6) frequently recovery takes place suddenly. 

Hysterical deaf-mutism is a rare condition, characterized by (1) sudden 
origin ; (2) absolute aphasia and aphonia ; (3) absence of signs of paralysis 
of the lips and tongue and of any paralytic phenomena except hysterical 
hemiplegia ; (4) preservation of intellectual faculties and power of 
writing ; (5) frequent coexistence of hysterical stigmata ; (6) usually 
rapid recovery. 



CHAPTER IX. 

THE DATA OBTAINED BY OBSEBVATION— ( Continued). 

The extremities — hands- The shape — temperament — occupation — "claw-hands" — 
"seal-fin hands" — rheumatoid arthritis — nervous affections — "spade" hands 
— large bones of acromegalia — osteo- arthropathy — wrist-drop. The movements 
— spasm — tremor. The skin— color — moisture. Fingers. Heberden's nodosities 
— contraction of fascia — Dupuytren's contraction — deviations in shape. The 
nails. Trophoneuroses — cold hands and feet. Raynaud's disease — erythro 
melalgia. 

THE EXTREMITIES. 

The Hands. 

The Shape. We bear in mind the variation in the form of the 
hand in different types of individuals — the broad and heavy hand of 
the sanguine, the slender, dexterous hand of an individual of the nervous 
temperament (see Chapter VI.), the large joints of the hand of so- 
called strumous persons, and the effeminate hand of the one who is 
inclined to tuberculosis, present sharp contrasts. Then, too, the l ' occu- 
pation " hand indicates in a general sense the disease the patient is 
liable to — none more striking than the hand of the miner, the blue- 
black dottings of which sharply indicate the possibility of anthracosis. 
Finally, we note the broad hand and clubbed fingers that are seen in 
congenital heart disease. The withered hand of age and wasting of the 
hands, as in phthisis or malignant disease, need not be referred to, as 
they are part of the general process. 

Fig. 13. 




Pseudo-muscular atrophy. Claw-hand 



Presenting more striking changes in shape are the peculiarly de- 
formed hands seen in affections of the muscles and joints. These 
deformities will be described in the respective sections (Chapters XII.. 



THE DATA OBTAINED BY OBSERVATION. 



Ill 



and XIII.), although in pas 



; m£ 



they may" be grouped together. First 



we have the " claw-hand " of progressive muscular atrophy , of innam- 



Fjg. 14. 




Rheumatoid arthritis. The tapering fingers are seen. The phalangeal joints are swollen ; many 
are anchylosed. The wrist is stiff. The muscles are atrophied ; the forearm-muscles much 
wasted. 

Fig. 15. 







Photograph of a case of lead-paralysis affecting the extensor muscles. (Gray. ) 

mation of the ulnar and median nerve, and of chronic poliomyelitis ; 
the " seal-fin" hand of chronic gout and rheumatoid arthritis, spasm 
of the extensor muscles causing deflection to the ulnar side. The 



112 



GENERAL DIAGNOSIS. 



gnarled hand of rheumatoid arthritis and the knotted hand of gout are 
characteristic. In the former the tapering, shining fingers, the bulbous 
phalangeal joints, the pallid, clammy surface, dotted with freckles, the 
locked joints, the atrophied muscles, combined with exquisite tender- 
ness of the involved parts, make a picture never to be forgotten. The 



Fig. 16. 




Examples of the positions of the fingers in the movements of athetosis. (StrUmpell.) 

peculiar deformity occurring in scleroderma is described in the chapter 
devoted to the skin. Then we have the deformity resulting from 
flexion of the hand on the forearm, the forearm on the arm as seen in 
cerebral palsies of children and in the hemiplegias. 



THE DA TA OB TAINED B Y OB SEE VA TION. 1 1 3 

The "spade-like" hands of myxoedema and the enlarged bones of 
the hands of acromegalia and pulmonary osteo-arthropathy are described 
in other sections. 

Deformities of the hand from other causes than the ones just men- 
tioned are often observed. Temporary contractures occur in tetany, 
in temporary hemiplegia or monoplegia, and in paralysis of the exten- 
sors. Dropping of the hand from the radius toward the ulna occurs in 
acute poliomyelitis from paralysis of the extensors. Then we have 
paralysis of the median, ulnar, and other nerves, with their character- 
istic deformity. (See Nervous Diseases.) So-called wristdrop is seen 
in peripheral neuritis (musculo-spiral nerve), and may be unilateral or 
bilateral. The hand hangs from the wrist on account of paralysis of the 
extensor muscles. Both hands may drop, although it sometimes happens 
that one is affected from a few days to a few weeks before the other. 

Jlovements. One can infer the limitation of movements of the hands 
in the affections described above. The stiffened and immobile hand 
of chronic rheumatism, in which enlarged joints are prominent, contrast 
with the painfully locked hand of rheumatoid arthritis. Involuntary 
movements, as tremors and spasms, are also observed. The tremor of 
age, of hysteria, of paralysis agitans, of exophthalmic goitre, of mer- 
curial and other intoxications, and of disseminated sclerosis, is most 
marked in the hands. It is in the hands and arms we see that most 
significant tremor or twitching with aimless picking at the bedclothes, 
described in an account of the typhoid state (Chapter XIV.), known 
as subsultus tendinum. Twitching and spasm of the hand or arm are 
seen in convulsive disorders, and may be unilateral or bilateral, as in 
hysteria, chorea, epilepsy, true and Jacksonian, tetanus, and tetany. 
When permanent, it is seen as an expression of a chronic cerebral 
process, as hydrocephalus. Alternating spasm and relaxation of the 
fingers, hand, and arm are seen in athetosis. 

Having noted the shape and movement of the hand, we direct atten- 
tion to the skin, the nails, and the fingers. 

The Skin. 

The skin of the hand need not be considered apart from the skin of 
the rest of the body. It is smooth or rough, dry and harsh, moist and 
warm, under the same circumstances that affect the skin generally. In 
rheumatoid arthritis it has been described as peculiar. Both the dorsal 
surface and the palm are moist and very soft, and the former is dotted 
with freckles. In progressive muscular atrophy and exophthalmic goitre 
the skin is moist. The cold, clammy skin of one laboring under excite- 
ment, as may be caused by the first visit to the physician, is well known. 

Color. The color of the hands is significant of the state of the cir- 
culation and the condition of the blood. The blue finger-tips and the 
pallid hand accompany similar color changes in the lips, and are early 
signs of cyanosis and of anemia. 

The swellings of the hand, inflammatory or cedematous, do not differ 
from swellings of the joints or the subcutaneous connective tissues in 
other portions of the body. Several exceptions are to be noted. First, 

8 



114 



GENERAL DIAGNOSIS. 



Fig. 17. 




the swelling that attends articular rheumatism with involvement of 
the wrist-joint extends over the dorsum of the hand frequently, while 
the fingers are free from the process. Second, a localized swelling on 
the dorsum of the hand is often due to a ganglion from a local affection 
of the tendons. Third, Gnbler's tumor is a swelling that is seen in 
wrist-drop from displacement backward of the carpal bones. Fourth, 
long-continued inflammatory swelling, with subsequent rupture of the 
skin, is seen in mycetoma. Finally, traumatic injuries produce tendo- 
synovitis, bone affections, and palmar abscess. Syphilis and gonorrhoea 
may be causal factors in the production of such processes, it is impor- 
tant to remember. (See Chapters X. and XIII.) 

The Fingers. 

In gout and rheumatism the joints of the fingers are enlarged and 
painful. The swellings of the joints of each condition cannot well be 
distinguished. In gout, tophi, hard, Avhite, sometimes glistening 
masses are likely to be present in the joints or along the tendons, on 

account of great accumulation of 
urate of soda. They are more promi- 
nent on the dorsal surface of the 
|^L X&"' joints, and sometimes break through 

mj ^vS ^k. e s ^ m ; so that the " chalk-like" 

» ^ concretion exudes. It was said by 

Sir Thomas Watson that a gouty sub- 
ject under his care used his joints to 
keep tally while playing cards. 

Heberden's Nodes. Haygarth's 
nodosities. The term " end -joint 
arthritis " is also applied to this con- 
dition. This node belongs to the 
first of the three divisions Charcot 
makes of rheumatoid arthritis. The 
nodules develop gradually at the 
sides of the distal phalanges. The 
subject may be in good health, or 
may have had attacks of gout, or 
have suffered from acid dyspepsia. 
At first the joints may be a little 
swollen and tender. The swelling 
and tenderness may be periodical, 
and the size may be increased with 
each fresh paroxysm. The tubercles 
are seen at the side of the dorsal 
surface of the second phalanx, the 
corresponding cartilage becomes soft, 
the ends of the bone may be ebur- 
natcd. A moderate anchylosis takes place. The nodules are often 
considered of good prognostic omen ; it is even said that they are a sign 
of longevity. It is certain that the large joints are rarely involved 
when these nodules are present. 



\ 




Heberden's nodes. 



THE DA TA OB TA I NED B Y OBSER VA TION. 115 

The tips of the fingers may be bulbous, or club-shaped, in some cases 
of phthisis and of other forms of chronic lung disease, and also of 
chronic heart disease. It is most common, however, in bronchitis and 
phthisis. The clubbing is associated with changes in the nails (see 
below and illustration of pulmonary osteo-arthropathy). 

Deviations in Position and Shape. Eversion is characteristic of 
rheumatoid arthritis, but deviations due to abnormal flexion or exten- 
sion are the most characteristic. Flexion of the first phalanx of the 
little finger is due to contraction of the palmar fascia or to paralysis of 
the common extensor from disease of the musculo-spiral nerve. Con- 
traction of the fascia of the hand, causing more or less flexion of the 
little and ring fingers, is frequently seen, and may be an indication of 
gouty diathesis. It is certain that these contractions are seen in several 
members or generations of a family in which gout is prevalent. It is 
called Dupuytren's contraction. 

Abnormal extension is usually very marked. Hyper-extension of 
the middle phalanx is due to paralysis of the flexor sublimis from 
disease of the median nerve ; hyper-extension of the distal phalanges 
to paralysis of the flexor profundus muscle from disease of the median 
and ulnar nerves. Extension of the proximal phalanx, with extreme 
flexion of the two distal phalanges, contributes to form the " claw- 
hand/' (See Muscles.) Contractions due to chorea or to central 
lesions, as post-hemiplegic contractions, will be considered under 
special diagnosis. It is thus seen that the peculiar combined exten- 
sion and flexion, causing abnormal shape of hands and fingers, is due 
to (1) local joint inflammation (subluxations) ; (2) local neuritis and 
paralysis ; (3) progressive (spinal) muscular atrophy ; (4) idiopathic 
muscular atrophy, rarely. 

The Circulation. Raynaud's Disease. Local Asphyxia. The 
hands or fingers become pale and intensely cold ; they are the seat of 
numbness, and are without sensation. The term ' i dead fingers " 
graphically describes the appearance. The pallor usually comes on 
suddenly, and continues for a variable period. As the pallor disap- 
pears there is a gradual return of warmth, and the color changes to 
a livid red, dark blue, or even blackish hue. The paroxysms of 
alternating pallid and livid hue may occur several times in twenty-four 
hours. In some cases the lividity becomes so intense that gangrene 
ensues in small superficial spots, or even involves the whole finger. 
Pain may or may not be present, and does not increase when the hand 
hangs down. In my experience it is more frequently present and ex- 
cruciating at the time the fingers are " dead." The tip of the nose 
and the lobe of the ear may be affected, and occasionally other parts of 
the surface. The sensitiveness to touch is markedly lessened. Ray- 
naud's disease occurs usually in ill-nourished subjects, or after an acute 
disease, as typhoid fever. It may be associated with vascular spasm 
in internal organs, giving rise to epilepsy, hemoglobinuria, temporary 
aphasia, or hemiplegia. It is usually worse in cold weather. 

Erythromelalgia. Local changes in color are often due to neuritis 
either of the trunk or of the terminal endings of the nerves. When 
such changes are associated with pain we use the term erythromelalgia. 



116 



GENERAL DIAGNOSIS. 



It is characterized by redness of the surface with increased tempera- 
ture ; it is usually seen in the extremities and is limited to the distri- 
bution of the affected nerve. It is worse in summer, increased by 
artificial heat, and aggravated when the extremity is dependent or 
pressed upon. The redness is attended by burning and extreme local 
discomfort, in which all sorts of sensations are described — tearing of 
the finger-nails, pulling or pricking of the skin, twistings of thousands 
of needles, and other forms of torture. I know of no peripheral pain 
which is the source of greater agony. 

Glossy skin is seen after nerve-injuries and neuritis, and in central 
affections in which the trophic nerves are involved. The skin is shiny, 
smooth, drawn very tightly over the surface, and sometimes atrophied. 
Red and pale mottling may be seen. The surface is free from hair. 
Burning pain precedes and accompanies the change. (See Nails.) 

The Nails. 

The Shape. The appearance of the nails enables us to estimate the 
duration of certain diseases, or the time when convalescence began ; it 
also indicates local interference with the nutrition of the parts. Thus, 
curving of the nails, with the club-shape of the finger-ends, occurs only 



Fig. 18. 




Clubbed fingers with curved nails (middle finger slightly flexed). 

in chronic diseases, as phthisis or emphysema, or in chronic cardiac 
disease and aneurism. In the latter it is sometimes found on one hand 
only. It is sometimes seen in other chronic wasting diseases. The 
nails may curve transversely or longitudinally. When transversely 
the appearance is like that of a filbert, and when longitudinally they 
are said to be incurvated. This change in shape may occur without 
clubbing of the fingers. The shape is altered in acromegalia and 
pulmonary osteo-arthropathy. (See Chapter XIII.) 



THE DATA OBTAINED BY OBSERVATION. 117 

Color. White marks on the surface are usually seen after an illness, 
and may indicate the date of recovery. The marks develop at the 
root of the nail, and as the nail grows the marks approach the tips of 
the lingers, and thus their position denotes the time that has elapsed 
since convalescence set in. If they are seen half-way up the nails, con- 
valescence is probably of three months' standing. We get a good idea 
of the condition of the blood in the capillaries from the appearance of 
the tissue under the nails. If there is anaemia, pressure on the finger- 
tips will drive the blood from the capillaries. Stephen Mackenzie's 
rule, that if such pressure completely empties the vessels so that they 
become pale, it indicates that the globular richness of the blood is re- 
duced one-half, is a fair and rapid test of the degree of the anaemia. 
The purplish and bluish-black discoloration of cyanosis previously 
referred to is first seen under the nails. Sometimes the capillaries 
pulsate, and this pulsation is more visible under the nails than in any 
other part of the body except the retina. It may occur in aortic 
regurgitation. 

Nutritive Changes. The nails undergo chronic inflammation with 
destruction in various skin affections, and the matrix is the seat of acute 
inflammation in onychia. Onychia may be simple or syphilitic. Its 
presence may indicate the organic origin of otherwise obscure nervous 
symptoms. It may be only a simple inflammation, or it may result in 
the loss of the nail and necrosis of the bone. 

Deformity of the nails (toe) occurs in acute and chronic myelitis. In 
locomotor ataxia the nails fall out. 

In neuritis the trophic change is marked ; the growth is arrested, 
and the nail becomes dark and brittle and curved in its long axis, while 
lateral arching takes place. The cutis underneath thickens and the 
skin at the base retracts. The fingers may be clubbed. When growth 
is resumed a distinct roughened line of demarcation is seen. In leprous 
neuritis there is destruction of nails and phalanges. Atrophy and ulcer- 
ation at the base of the nails, followed by necrosis of the phalanges, is 
seen in so-called Morvan's disease, which is not really a disease but a 
symptom of neuritis or syringomyelia. Enlargement with thickening 
and sometimes twisting occurs after fevers, as typhoid, or in the course 
of syphilis and in sclerodactyle. The nutrition is changed in Ray- 
naud's disease. In some cases the nails become dry, scaly, and cracked, 
or hypertrophied entirely. In the hemiplegia from cerebral apoplexy 
the growth is arrested on the paralyzed side. This is tested by stain- 
ing the nails of the two hands at the same level with nitric acid ; the 
relative position of the stain upon corresponding nails of the two hands 
will show whether there has been growth or not. The return of func- 
tional power is indicated by renewed growth. 

The Feet. 

Enlargement or deformities of the feet and legs may be due to 
changes in the joints, the bones, and the subcutaneous connective 
tissue. Hence we would have swelling due to oedema and myxoedema, 
and enlargements due to acromegalia and pulmonary osteo-arthropathy. 



118 GENERAL DIAGNOSIS. 

The chapters so frequently referred to will contain a discussion of these 
subjects, and to the Chapter on Joints must be referred all articular 
changes. It must be recalled that pain may be due to flat-foot and to 
neuralgia of the third interosseous nerve. (See Pain.) Flat-foot must 
always be looked for when inability to walk is complained of. Changes 
in the shape of the foot from muscular affections will be described, 
bearing in mind that " claw-foot " is a prototype of " claw-hand/ y 
found in progressive muscular atrophy and in Friedreich's ataxia. 

Three nutritional changes take place in the feet that are of diagnos- 
tic significance : perforating ulcer of the foot, a trophic change occur- 
ring in locomotor ataxia ; gangrene, the result of endarteritis (usually 
senile), or occurring in the course of diabetes mellitus ; mycetoma, or 
" Madura foot." Perforating ulcer usually begins as a blister, then an 
abscess, and finally an ulcer. 

The nails of the feet are subject to the same changes that take place 
in the nails of the fingers. 

Cold Hands and Feet. Patients frequently complain of coldness 
of the extremities. It is a common and often serious complaint. It 
is natural to expect a peripheral coldness when the central organ of 
circulation is weakened. Coldness takes place in the final hours pre- 
ceding death. It occurs in collapse, in hemorrhage, and in shock. 
But we also see it in organic disease of the heart, with impairment of 
the circulation. It is a common vasomotor condition in nervousness, 
independent of hysteria. It is a marked feature in NothnageFs angina 
pectoris vaso motoria, as well as in true and false angina pectoris. 
A visit to a physician, or excitement from any cause, is likely to be 
attended by coldness of the hands and feet. Under these circum- 
stances the extremities are often bathed in a cold and clammy perspi- 
ration. In senile endarteritis cold hands and feet frequently occur. 

They are an index to the state of the peripheral circulation in other 
parts of the body, as the brain. 

The poisons of gout, of rheumatism, and of other diseases, which irri- 
tate peripheral and vasomotor nerves, may cause cold hands and feet. 

In gastric and intestinal dyspepsia, with the absorption of toxic prin- 
ciples, as leucomaines, this symptom may be present. 

Changes of sensation in the skin of the extremities will not be con- 
sidered in this section. They will be taken up in the chapters devoted 
to the diseases of the nerves. It is sufficient to state that anaesthesia 
in local areas, and due to causes limited to the skin, is seen in morphoea, 
in the anaesthetic form of leprosy, and in certain ischsemic states (urti- 
caria). It is accompanied by loss of tactile sensibility. Hyperesthesia 
and parcesthesia occur with various local affections, but they are with- 
out diagnostic significance except in nervous diseases. 



CHAPTEK X, 

THE DATA OBTAINED BY OBSEEVATION— {Continued). 

The skin. The color — redness — pallor — jaundice — cyanosis — the bronzed skin — Addi- 
son's disease — hemochromatosis — chloasma — tinea versicolor — vagabond's dis- 
ease — argyria — freckles. The nutrition. Moisture and dryness — hyperidrosis 
— anhidrosis. Scars Hemorrhages — mode of recognition — cause — significance. 
Eruptions — their clinical significance — nature of the lesion — distribution — asso- 
ciate morbid phenomena — general symptoms. Table of skin diseases — erythema 
— herpes —erythema nodosum — urticaria — medicinal rashes — erythema of infec- 
tious diseases — roseola — miliaria or sudamina. General diagnosis. 

THE SKIN. 

Color. The portions exposed to the air exhibit more varied and 
pronounced changes of color than parts that are covered. The changes 
in color herein described refer more particularly to the face and hands. 
The color of other parts partakes of the same tint as that of the face, 
other things being equal, except that the intensity is less. Comparison 
of the two should always be made, and the mucous membranes examined, 
as control observations. For the latter the conjunctiva?, lips, and mouth 
are sufficient, always remembering the possibility of hyperemia of the 
conjunctiva from other causes. 

Local color changes of the face will be particularized in this section. 
It is not to be forgotten that the color varies with the type — whether 
blonde or brunette — and that variations in the latter at times easily 
escape recognition. 

The skin in a healthy child is of a faint pink color ; as age advances 
it loses its fresh appearance and becomes paler, except in those whose 
occupation exposes them to atmospheric influences. In the latter, the 
skin becomes weather-stained, and may assume a mahogany or reddish- 
brown hue. In old age, the color is apt to deepen and become duller, 
while the loss of subcutaneous fat allows the skin to lie in folds, espe- 
cially about the jaws and neck, and wrinkles are marked, especially 
between the eyebrows, over the nose, and at the angles of the eyes and 
mouth. 

Apart from these changes, which are physiological or necessarily the 
result of occupation, the skin exhibits changes which are the result of 
the habits or health of the individual. Some persons, especially if 
blondes, retain to old age the fresh, pink skin of childhood. In others 
is seen early a dull, muddy complexion. This is common in those 
who use coffee to excess and are habitually constipated. In others 
digestive derangements, particularly constipation, uterine disorders, or 
gouty derangements produce, in addition to a muddy complexion, crops 
of acne and comedones, or black-heads. It must be admitted, however, 



120 GENERAL DIAGNOSIS. 

that some persons preserve a fresh complexion in spite of marked 
digestive disturbance. Considerable congestion of the superficial blood- 
vessels, giving a person a florid appearance, may be due, especially in 
a young person, to alcoholic excesses ; and there is a popular belief 
which connects such an appearance, when coupled with a tuberous nose 
and a crop of angry-looking pustules, with a prolonged use of spirits. 

The sebaceous glands of the skin of the face merit but a passing 
notice. Deficiencies or excesses of secretion, or alteration of it, are 
usually due to local causes. Excessive secretion of sebaceous matter, 
known as seborrhoea, or steatorrhea, is seen in two forms. First, with 
oily exudation ; second, with drying of the secretion and the formation 
of crusts. It may be more pronounced in strumous subjects. The 
opposite condition, or asteatodes, is seen in wasting diseases, particularly 
diabetes, and in xeroderma and ichthyosis. 

Color Increased. The Abnormally Red Skin. Physiological 
hyperemia has been spoken of. The color is intensified when the 
capillaries are overfilled or the blood-current is unusually rapid. The 
hyperemia may be general or local, and is due to dilatation of the capil- 
laries, possibly from nerve-influences. General hyperemia is seen in 
fever, in poisoning from atropine, and from organic poisons derived 
from food or the result of intestinal putrefaction. 

Local hyperemia attends the phenomena of blushing, and comes and 
goes in nervous persons with every psychical impression. Rarely in 
neurasthenics the hyperemias may be extreme, amounting almost to an 
erythromelalgia. Abnormal redness may be diffused over the whole 
face or may present the circumscribed flush of phthisis ; the local deep- 
red area, on one cheek, of pneumonia ; the evanescent flush of anemia, 
with cardiac palpitation ; and the creeping flush, with raised border, of 
erysipelas, appearing on the bridge of the nose or at the nostril. In 
phthisis, moderate excitement or exertion, the taking of food, or the 
onset of fever, tinges the cheek with the blush of hectic. In migraine, 
the burning flesh may be limited to one side. Capillary congestion on 
the cheeks or on the tip of the nose occurs with the endarteritis of the 
aged, but is seen also in early life in cases of hepatic cirrhosis or of 
obstruction of the hepatic circulation from other causes. 

Color Lessened. It is caused by diminution of the amount of 
blood in the capillaries, or because its richness in haemoglobin has been 
reduced. 

Pallor. Diminished amount of blood in the capillaries occurs 
from active contraction or spasm of the arterioles, from hemorrhage, 
or from weak heart. The pallor, therefore, is usually acute or tem- 
porary, and may be recurrent. It attends fright, syncope, or nausea 
and vomiting. It occurs also in acute poisoning, in acute disease, such 
as diphtheria, and in hemorrhage. The pallor due to loss of blood 
may be instantaneous if the hemorrhage is sudden and large, or develop 
gradually if it is small and continued over a long period. The onset 
of sudden pallor is of diagnostic significance in diseases in which hem- 
orrhage may occur, as in aneurism, gastric or intestinal ulcer, and 
typhoid fever. Symptoms of collapse are seen with this form of 
pallor. 



THE DA TA OB TA IN ED B Y OB SEE VA TION. 1 2 1 

Pallor of long duration, or chronic pallor, if we may so term it, is 
seen in a number of diseases. In all of them there are diminution in 
the amount of red corpuscles and destruction of the haemoglobin. It 
is characteristic of blood affections, as the various forms of anaemia. It 
does not necessarily occur in leucaemia ; indeed, the cheeks and lips 
may be red. It is seen, in a striking form, in chronic" Bright's disease, 
in cancer, in chronic poisoning, as from lead or arsenic, in chronic 
catarrh of the stomach or of the bowels, and in chronic infectious pro- 
cesses, as tuberculosis and syphilis. 

While paleness is recognized as the fundamental or prevailing color 
of the skin in many of the above-noted affections, a further tinge gives a 
characteristic hue to the skin ; thus, in chlorosis there is a greenish 
appearance of the face, which is in striking contrast to the pearly col- 
ored conjunctivas. In carcinoma the yelloimsh tinge of the pallor often 
causes it to be mistaken for jaundice. In pernicious anmnia a straic- 
colored appearance of the skin has been frequently described, which 
may cause it to be mistaken for carcinoma. It is worthy of remark 
that the cachectic pallor in carcinoma is not likely to occur unless 
there are primary or secondary deposits in the gastro-intestinal tract or 
the liver, and it is well known that pernicious anaemia is usually sec- 
ondary to gastric or hepatic disorder. The peculiar hue of the pallor, 
therefore, may be due to a common cause in these affections. The 
pallor that attends Bright* s disease is usually associated with slight 
puffiness under the eyelids, or local dropsical accumulations elsewhere. 
In chronic poisoning with lead pallor is associated with a blue line 
upon the gums and drop-wrist ; while in arsenical poisoning there are 
frequently associated a puffiness of the eyelids and looseness of the 
bowels. 

It is not well to lay much stress upon the variations in hue of the 
pallor. They are not of diagnostic importance in themselves, but only 
when associated with the characteristic symptoms and signs of the 
respective affections in which this hue occurs. 

It must not be forgotten that there are a large number of individuals 
in whom pallor is the normal condition. This is particularly the case 
with those who lead a sedentary life and are confined within doors. 
There are a number of occupations which predispose to pallor. 

Abnormal Color. I. The Yellow Skin. Jaundice. The yel- 
low coloration is seen not only in the skin but in the sclerae (see the 
Eye) and the mucous membranes. The discoloration of the skin is not 
difficult of recognition. It varies in shades from a slight yellow hue to 
yellow-green or olive-green, and in many forms of jaundice to brownish- 
yellow. The yellow hue of the skin in jaundice may be preceded and 
is always accompanied by tingeing of the conjunctivae ; its presence in 
this situation confirms the observation. The mucous membrane under 
the tongue early gives evidence of jaundice ; or, if the lips are everted 
and a glass slide pressed evenly on the surface, the yellow discoloration 
of the mucous membrane will shine through. 

The yellow tint of the conjunctivae must not be confounded with the 
same color due to subconjunctival fat. The latter is not uniform in the 
conjunctivae, but may occupy cone-shaped areas. 



122 GENERAL DIAGNOSIS. 

The physiological yellow color of the skin that is seen in infants 
shortly after birth is not a true jaundice, but in all probability arises 
from excessive destruction of red corpuscles in the over-congested 
skin. On light pressure with the finger the color changes. It 
fades from shades of yellow into the genuine flesh-color. The con- 
junctivae are natural, and the urine is free from bile-pigment. 
The faeces are normal. By these symptoms a distinction can be 
made. 

Jaundice is a symptom due to a number of diseases. In the first 
place, it is most frequently due to disease of the liver ; this form is 
known as hepatogenous jaundice. It may possibly be due to destruc- 
tion of the corpuscles of the blood and liberation of the haemoglobin, 
the so-called hcematogenous jaundice. The various causes of the former 
will be considered under diseases of the liver. The latter is said, not 
without objection, to be due to destructive agencies in the blood, such 
as ptomaines, which are absorbed in gastro-mtestinal disease, or to 
poisons that develop in the course of pyaemia, yellow fever, malarial 
and relapsing fevers ; it may also be due to snake-bite or to poisons that 
are imported, as in mineral poisonings, or chloroform, ether, or chloral. 
In both instances the yellow coloration of the skin is due to coloring- 
matter of the bile or of the blood, or bilirubin, which is deposited in 
the cells of the rete mucosum. 

Other symptoms due to the same cause are associated with hepato- 
genous jaundice. Their presence may be of diagnostic value in deter- 
mining the nature of the yellow color of the skin in cases of doubt. 
These symptoms are : (1) Itching. This symptom is intolerable ; the 
surface of the body is often seen to be covered with scratch-marks on 
account of the irritation of the peripheral ends of the nerves in the skin 
by bile-pigment. (2) Slow pulse. Slowness of the pulse also fre- 
quently attends jaundice. (3) Secretions and excretions. The saliva, 
or expectoration, if present, is bile-tinged, and the urine is dark col- 
ored, due to the presence of the pigment. (See Urine.) While the 
excretions are all tinged with bile in the hepatogenous form, the faeces 
are free from bile, hence they are pale or of an ashy color. On account 
of the absence of bile in the intestines its physiological effects are lost, 
and therefore flatulency from fermentation becomes an important 
symptom. 

II. The Blue Skin. Cyanosis. This peculiar hue is recognized 
without difficulty. The bluish or bluish-red appearance of the skin is 
first seen at points furthest from the central organ of circulation, as in 
the extremities. The mucous membranes, in which the capillary cir- 
culation is readily seen, also exhibit the change early. It is early seen 
also in the finger-tips, particularly underneath the nails, about the 
phalangeal joints, and in the lips. Subsequently the entire surface of 
the skin may become dusky or cyanosed, as its cause increases in 
degree. Its onset, it is said, can be anticipated by the state of the 
veins on the under part of the tongue ; overfilling or extreme disten- 
tion of these vessels always occurs in cyanosis. At first the color, 
wherever situated, usually disappears on pressure, but as the hue 
deepens it remains in spite of pressure. 



THE DATA OBTAINED BY OBSERVATION. 123 

Causes. Cyanosis is (1) respiratory, due to overfilling of the veins 
and capillaries with blood not sufficiently oxygenated, or (2) vascular, 
to an excess of venous blood, oxygenation not being interfered with. 

1. Respieatoey. All conditions which interfere with the aeration 
of the blood cause more or less cyanosis. Practically sufficient air 
cannot get to the blood, or sufficient blood to the air. Obstruction of 
the air-passages, diminution of respiratory area, and diminished or in- 
efficient respiratory movements prevent oxygen getting into the blood ; 
interference with the circulation in the lungs prevents the blood getting 
air. Both causes are often combined. 

a. Obsteuction of the Aib-passages. This may occur in the 
upper respiratory tract, or in the capillary bronchi. (1) Fauckd ob- 
struction, by pharyngeal abscess or tonsillitis, or, in rare cases, by 
diphtheria, causes moderate cyanosis. (2) Obstructive laryngeal dis- 
eases produce cyanosis varying in degree with the amount of obstruc- 
tion and its persistence. The cyanosis is of short duration in spasmodic 
croup and in laryngismus stridulus ; it is prolonged in the more per- 
sistent inflammatory affections. Its gradual onset, in moderate degree, 
as seen by the purple lips or dusky finger-tips, is of serious prognostic 
import in the course of tuberculous laryngitis even if symptoms of 
grave obstruction have not arisen. (3) Tumors, pressing on the trachea 
or bronchi, narrowing the air-channel, cause cyanosis. The tumors 
may be situated in the neck, as the thyroid gland, or within the medi- 
astinum. (4) Spasm of the bronchi, as in asthma, occlusion of the 
bronchioles, as in bronchitis, both acute and chronic, and particularly 
the grave forms of capillary bronchitis in childhood, cause cyanosis. 
(5) Foreign bodies anywhere in the upper regions of the respiratory 
tract are fruitful sources of cyanosis. 

b. Diminution of the Respieatoey Aeea. Cyanosis from this 
cause occurs in pneumonia, in cedema of the lungs, in tuberculosis, and 
in all forms of pleural effusion and of intrathoracic tumors compressing 
the lung. It is an important diagnostic feature of acute tuberculosis. 

c. Diminished oe Insufficient Respieatoey Movements. De- 
ficient chest-expansion, because the action of the respiratory muscles is 
interfered with, lessens the respiratory area. This interference may 
be either on account of muscular or pleuritic pain, on account of paraly- 
sis, or, in the case of the diaphragm, on account of upward pressure by 
accumulations in the abdominal cavity, as large peritoneal effusions, an 
enlarged liver or spleen, or an abdominal tumor. In bulbar paralysis 
and peripheral neuritis, in paralysis of the diaphragm, and in spasm of 
the muscles of respiration (as in tetanus) there is diminished respira- 
tory movement. In forms of progressive muscular atrophy and in other 
rare affections of the muscles, as trichinosis, cyanosis is also observed 
for the same reasons. 

d. Obsteuction of the Pulmonary Vessels. Interference with 
the circulation within the lungs, from pressure on the pulmonary artery 
or vein by aneurism or mediastinal tumor, or from disease of the heart 
itself, is a most frequent cause of cyanosis. In affections of the heart it is 
not seen until — in the case of valvular disease, for instance — compensa- 
tion is lost and the right heart is dilated, causing an accumulation of 



124 GENERAL DIAGNOSIS. 

blood in the lungs. In the latter condition the bronchitis of passive con- 
gestion of the mucous membrane is an additional cause for the cyanosis. 

2. Cardiovascular. Obstruction to the flow of venous blood 
anywhere in the circulation will lead to the development of cyanosis. 
This is the cyanosis of passive congestion. Cyanosis due to causes 
mentioned above is always general. Cyanosis arising from the causes 
indicated in this section may be general or local, depending upon the 
seat of obstruction. General cyanosis may occur in (1) congenital 
heart disease ; (2) in valvulitis, when compensation is lost and dila- 
tation has taken place ; (3) in incompetency of the valves from 
dilatation ; (4) in weak heart or enfeebled action from pericardial 
effusion. In congenital heart disease the cyanosis is so great and so 
persistent that the affection has been termed " blue disease " or " morbus 
CQ3ruleus." 

Local cyanosis is seen when there is obstruction of the venous trunks 
from external pressure, or from disease of the venous wall, causing 
thrombosis. It may be limited to the head and upper extremities, in 
obstruction of the descending cava by tumor or aneurism, or to the 
lower portion of the trunk and the lower extremities in obstruction of 
the ascending cava by pressure from tumors within the abdomen and 
thorax. One extremity may be the seat of local venous stasis from 
pressure upon the veins, or its occlusion by thrombosis ; the arm in 
cases of cancer of the breast and axillary glands, the leg in cases of 
femoral phlebitis, represent typical forms of venous stasis. A striking 
form is due to causes affecting the vasomotor nerves, giving rise to 
peripheral capillary spasm. (See under Fingers, Kaynaud's Disease.) 

III. The Bronzed Skin. Pigmentation. Addison's Disease. The 
most marked form of bronzing is seen in Addison's disease — an affec- 
tion characterized by a gradual loss of strength without much loss of 
flesh ; by gastric uneasiness and occasional vomiting ; feeble circula- 
tion, and a bronze hue of the skin. 

Social History. The disease occurs most frequently during the active 
period of life, from the age of twenty to forty years, and nearly twice 
as often in males as in females. 

Asthenia. The disease begins insidiously with gradual and progres- 
sive loss of strength. It becomes evident from the patient's languor, 
weariness on slight exertion, and inaptitude for mental effort that he 
is suffering with some exhausting disease. The most characteristic 
symptom is the extreme prostration without any obvious cause. Any 
exertion requires great effort and may induce fainting. 

Gastric Symptoms. The appetite is impaired or lost, there is more 
or less discomfort at the epigastrium, and occasional vomiting. 

Perhaps at this time a close inspection may show some discoloration 
of the skin, but usually this appears later. By degrees the gastric 
symptoms become more prominent, and vomiting may be so frequent 
as to shorten life materially. Finally, the patient is unable to leave 
the bed. Dull pains in the head, back, and abdomen are not uncom- 
mon ; neuralgic pains in the limbs may be complained of ; and Osier 
states that there is tenderness on pressure in the lumbar region in a 
considerable proportion of cases. 



PLATE II 



>^ 



&*^ 



% 







Addison's Disease, Showing Bronzing of Skin, and White 
Areas of Atrophy. (Coleman.) 



THE DATA OBTAINED BY OBSERVATION. 125 

The pulse is extremely small and feeble ; in the later stages it may 
be absent at the wrist. 

Bronzing. The discoloration of the skin is the most striking symp- 
tom of the disease when it is well marked. The external surfaces are 
changed in hue, and delicate portions of the skin underneath the cloth- 
ing are also bronzed. The discoloration is not removed by pressure. 
The areas are irregular in shape. The skin is soft and pliable. The 
pigment which causes the discoloration is deposited in the rete Mal- 
pighia. 

The pigmentation is never seen in the cornea or in the nails. The 
axilla, the flexure of joints, the median line, the areola about the nipple 
and other normal areas of pigment deposit are the common sites. 
Bronzed areas in sharply circumscribed patches are also seen in the 
mucous membrane of the lips and cheeks. 

Sometimes the whole body becomes of a walnut-juice color, a bronz- 
ing which is deeper in exposed surfaces. At times only portions of 
the body are discolored, in which case the dark hue shades off grad- 
ually into the normal hue of the skin. Wilks 1 states that in all the 
cases which he has seen the scalp, finger-nails, soles of the feet, and 
palms of the hands escaped pigmentation. 

Nevertheless, discoloration of the skin is not an essential symptom 
of the disease ; in some cases it is entirely absent. These cases, espe- 
cially if associated with much vomiting, run a more acute course than 
the others, lasting only a few weeks. Such cases have been mistaken 
for typhus fever. 

On the other hand, diseases of the suprarenal capsules not usually 
associated with the Addison symptom-complex, as carcinoma, are 
attended by pigmentation. In about an equal proportion of cases it 
is absent, however. 

The discoloration of the skin in Addison's disease must not be con- 
founded with that of sunburn. The latter discoloration is limited to 
parts that are exposed to the sun, is more uniform, and the mucous 
membranes are free. Moreover, the ansemia and debility of Addison's 
disease do not attend it. The pigmented areas in the mucous mem- 
brane of the mouth, seen in a certain class of negroes, must not be 
mistaken for the pigmentation of Addison's disease. (See Plate II.) 

In persons living in filth general discoloration of the skin takes place, 
known as " vagabond's disease ;" but because it is so general and the 
skin is rough and thickened, and other evidences of filth are seen, it 
can easily be recognized. In the latter stages of jaundice the dark- 
green, olive, or black hue of the skin might be taken for the general 
bronzing of Addison's disease. The appearance of the conjunctiva is 
sufficient to indicate the cause of the bronzing. In certain cases of 
tuberculous peritonitis, even if the adrenals are not involved, the pecu- 
liar brown discoloration which simulates Addison's disease is present. 
In scleroderma pigmentation occurs, although rarely. 

The pigmentation that occurs in uterine disease or in pregnancy (uterine 
chloasma) resembles the bronzing of Addison's disease. It is usually 

1 Keynolds' System of Medicine, Philadelphia, 1880, iii. 561. 



126 GENERAL DIAGNOSIS. 

confined to the forehead and cheeks and the normal pigmentary areas of* 
the skin. The mucous membranes are not affected, although in pregnancy 
there may be the characteristic change of the vaginal mucous membrane. 
The vomiting and weakness that attend pregnancy may sometimes lead 
to confusion — vomiting is early, pigmentation late in pregnancy. 

The affections just described must not be confounded with the dis- 
coloration — yellowish-brown in hue — of tinea versicolor, a parasitic skin 
disease. The latter is recognized by its color and irregular dissemina- 
tion. It especially occupies the chest and spreads to the abdomen. It 
rarely ascends above the neck. It does not usually, therefore, occur 
in parts exposed to the air, or in parts that are the seat of normal pig- 
mentation. Then, again, the surface desquamates in brownish scales. 
Examination of the scales in a drop of dilute liquor potassse, under the 
microscope, shows both spores and mycelium. The spores are of the 
fungus micro-sporon furfur. Another skin affection is attended by 
bronzing — leukoderma. In diabetes bronzing is often seen independently 
of any parasitic invasion of the skin, and apparently the result of the 
cachexia. It is possible that it is due to the cirrhosis of the liver 
which causes the glycosuria. But if the pancreas is primarily at 
fault the skin change is more likely to occur. In certain forms of 
hepatic cirrhosis, as so-called Hanot's, or the hypertrophic form, 
bronzing, undoubtedly the result of blood destruction, hcemochroma- 
tosis, is seen in rare instances. 

At times the bronzing and other characteristic symptoms of Addi- 
son's disease are associated with tuberculosis in other organs. Con- 
versely, in cases of phthisis in which there is bronzing, tuberculous 
disease of the suprarenal capsules may be suspected, and it adds to the 
gravity of the prognosis. 

Argyria. If nitrate of silver is administered over a long period of 
time, fine black particles of the metal or of the albuminate are deposited 
in the kidneys, the intestines, and the skin. The corium is the principal 
seat of the deposition. The discoloration of the skin is gray or gray- 
ish-black. It is not changed by pressure, and is usually limited to the 
face and hands. Small specks may also be noted in the mucous mem- 
brane of the mouth. The cornea and nails are not affected. Persons 
are usually in good health, although the presence of the skin-change, if 
seen in a patient with coma, would point to the possible presence of 
epilepsy, on account of which the drug had been taken. 

Freckles. Freckles are not usually of special diagnostic significance. 
Their occurrence in an unusual degree on the back of the hand and 
forearm has been observed, however, in cases of rheumatoid arthritis. 

Hemorrhages. 

Hemorrhages in the skin are called, according to their size, petechia^ 
ecchymoses, vibices, and hcematomata. The petechia? and ecchymoses are 
apt to appear in the hair follicles, and vary in size from a pin-point to 
a split pea. 

Mode of Recognition. They must be distinguished from erythe- 
matous and other eruptions. They may be raised above the surface of 



THE DA TA OB TAIN ED B Y OBSER VA TION. 127 

the skin ; they do not disappear upon pressure, and vary in hue from 
deep red to yellow-brown, according to their depth beneath the surface 
and to the degree of absorption that has taken place since the hemor- 
rhage occurred. 

Vierordt advises the following test to distinguish them from erythe- 
mas : Press a piece of glass (a microscope slide) upon the suspected 
spot. A hemorrhage is rendered more distinct, while the surrounding 
part becomes more anaemic. An inflammatory hyperemia, on the 
other hand, disappears. 

Cause. Hemorrhages may be due to affections of the blood or dis- 
ease of the bloodvessels. They occur in the course of blood diseases, 
because such change in the quality of the blood takes place that permits 
diapedesis more readily. They are more particularly, but not exclu- 
sively, seen in dependent parts, especially in the lower extremities. 

Significance. While subcutaneous hemorrhages are easily recog- 
nized, their diagnostic significance is more difficult to determine, and 
must depend upon the phenomena with which they are associated. 
Moreover, the situation of the hemorrhage is in a measure an index of 
its causal origin ; thus hemorrhages about joints are usually purpuric 
or hemophilic. 

1. Hemorrhage with Fever. Subcutaneous hemorrhages in the 
infections are due to changes in the quality of the blood, and indicate 
the severity of the infection, or to obstruction of the bloodvessels with 
emboli. To the former class belong cerebrospinal fever and measles, 
variola, and scarlatina. In the exanthemata they precede, develop with, 
or even replace the characteristic eruption, the latter being darker in 
color than normal. Hemorrhages will probably take place at the same 
time from the mucous membranes ; perhaps the nares will be occluded, 
and the mouth and fauces filled with clotted blood. In milder infections 
sordes collect in the mouth only. They indicate the degree of malignancy 
of these affections. To the same class of affections belong epidemic 
hemoglobinuria and morbus maculosus neonatorum, diseases of newborn 
infants but little understood, although no doubt of an infectious nature. 
To these may be added the severe forms of purpura hemorrhagica, 
attended by fever, marked visceral disturbances, skin eruptions, and 
great oedema. 

Hemorrhages due to obstruction of the vessels are known as hemor- 
rhagic infarcts, and are seen in pyaemia, and ulcerative endocarditis. The 
hemorrhages are small, sometimes elevated, more abundant on the 
extremities, but distributed over the trunk ; they are seen as small 
areas in the mucous membranes, observed in the conjunctivae, and, on 
ophthalmoscopic examination, in the retina. The association of chill, 
fever, and sweat, the presence of pus in some structures of the body, 
and the characteristic joint affections point to pyaemia. On the other 
hand, if due to ulcerative endocarditis, the physical signs of this affec- 
tion render the recognition of the cause of the hemorrhage clear. 
Finally, in rheumatic fever with involvement of the joints we have the 
occurrence of purpura. (See Erythema, same chapter.) 

2. Hemorrhage with Anaemia. Hemorrhages occur in all forms 
of anaemia attended by debility. In idiopathic or pernicious ansemia 



128 GENERAL DIAGNOSIS. 

they are usually small, but may become extensive. They occur on the 
extremities, and, usually, on the dorsum of the feet or hands. There 
may also be retinal hemorrhages. They are also seen in the secondary 
anaemias that arise in the later stages of tuberculosis and of carcinoma, 
particularly of the stomach ; in the later stages of Bright' s disease, and 
of cirrhosis of the liver. 

Scurvy is an affection characterized by anaemia, debility, and wasting, 
in which there are hemorrhages under the skin as well as from the 
mucous surfaces. The gums are particularly affected. They bleed 
easily. Hemorrhages also occur in the deep lymphatic spaces, in the 
muscles, underneath the periosteum, and in the joints. In scurvy- 
rickets similar hemorrhages are seen. (See Chapter XIII.) 

3. Purpura. Primary purpura occurs without any known cause. 
It has been divided, for convenience, into simple and hemorrhagic 
purpura, though the two probably differ only in intensity. 

Secondary purpura occurs in connection with a variety of febrile and 
constitutional diseases : 1. Scurvy. 2. Haemophilia. 3. Hodgkin's 
disease. 4. Splenic leucocythaemia. 5. Pernicious anaemia. 6. Chronic 
lesions of the kidney and liver, with or without jaundice. 7. Ulcera- 
tive endocarditis. 8. Malignant sarcomata. 9. Infectious diseases. 

A. In simple purpura the hemorrhages are limited to the skin. 
They consist of : 1. Bright-red spots, varying in size from a pin- 
head to a silver three-cent piece. These spots are under the skin 
and are unaffected by pressure. They fade gradually from red to 
yellow and disappear. 2. Larger spots or streaks called vibices. 3. 
Ecchymoses. 

The disease is said to be most common about the age of puberty. 
It may come on in the midst of apparent health, or it may follow an 
illness, as typhoid fever. 

Purpura occurs especially upon the legs, the standing position seem- 
ing to favor its occurrence. It comes on in successive crops. Some- 
times large blebs, filled with thin blood, form under the skin, and 
gangrene at times occurs. 

B. In the hemorrhagic form 1 hemorrhages occur from the nose, 
stomach, bowels, vagina, and bronchi, or into the kidney or other 
viscus. Cutaneous and submucous hemorrhages also occur. 

The onset of these cases is sudden, though there may be a day or 
two of depression, lassitude, headache, and nausea. The first symptom 
noticed is generally fever, which is apt to be moderate, then eruption 
upon the skin is detected, and for a day or two the patient may seem 
to be only slightly ailing. Copious epistaxis may now occur, or a 
haematemesis or haematuria, or all of these and other hemorrhages, may 
occur the same day. The temperature may be only moderately raised, 
or it may reach 104° to 105°, or even a higher point. The pulse at 
first is frequent (120 to 140), but of good volume and tension. Subse- 
quently, in unfavorable cases, it becomes thready and very frequent. 
Respiration is not affected, and the mind is clear ; the face is pale and 

1 See Grave Forms of Purpura Hemorrhagica. Musser: Trans. Association of 
American Physicians, vol. vi. 



THE DATA OBTAINED BY OBSERVATION. 129 

anxious. Hemorrhage may also occur into the choroid and brain- 
substance, with blindness and paralysis as sequels. It may also occur 
into the uvula or tonsil. 

The subjective symptoms are pains in the loins, limbs, epigastrium, or 
chest. Often these pains announce a fresh hemorrhage, as into the 
kidney, or a fresh crop of purpuric spots. The degree of ansemia 
depends upon the copiousness of the hemorrhage and the length of time 
the disease lasts. Sometimes the hemorrhages cause great exhaustion, 
with a tendency to collapse. 

The urine, in the case of hemorrhage into the kidney, of course 
contains blood ; sometimes casts are also found. 

C. Another variety of purpura is known as peliosis rheumatica, the 
peculiar features of which are tender and swollen joints, oedema of the 
subcutaneous cellular tissue, and purpura associated with urticarial 
wheals and intense itching (purpura urticans). The subcutaneous 
hemorrhages consist of petechia?, vibices, and ecchymoses. There may 
be such large hemorrhages into the penis, scrotum, and uvula as to 
result in gangrene and slow separation of the dead tissue by ulceration. 
Epistaxis may occur, but copious hemorrhages from the stomach, the 
bowel, or into the kidney or other organs are rare. Endocarditis and 
pericarditis occur as complications in some cases. The duration is 
apt to be long, convalescence being delayed by repeated outbreaks of 
purpura with multiple arthritic symptoms and oedema. 

Diagnosis. It is distinguished from scurvy by the absence of ante- 
cedent debility and ansemia, of spongy gums, of brawny induration in 
the limbs, and by the fact that the hemorrhages do not usually occur 
around a hair follicle. In scurvy there is a history of deprivation of 
vegetable food, whereas purpura may occur in the midst of robust 
health. As a rule, the cutaneous hemorrhages are larger in scurvy 
than in purpura. 

It is distinguished from acute infectious diseases, particularly typhus, 
cerebro-spinal fever, and smallpox, by the absence of severe constitu- 
tional symptoms which characterize the graver forms of these diseases 
— in which alone a purpuric eruption is likely to be severe enough to 
cause doubt. Hemorrhages from mucous surfaces are rare in the 
latter. 

Haemophilia is distinguished by the history the patient gives of being 
a bleeder by heredity, and the fact that the bleeding has been started 
by some injury, wound, or operation. 

It is distinguished from the hemorrhages of leukwmia by the absence 
of enlarged spleen and liver, and by the fact that there is no excess of 
leucocytes in the blood. 

Malignant sarcoma causing hemorrhages is recognized by the pre- 
vious history of anaemia and cachexia, anol by the detection of primary 
or secondary growths. 

It must not be confoundeol with Raynaud's disease, a vasomotor 
affection characterized by local syncope, local asphyxia, and gangrene. 

4. Haemophilia. The diagnostic significance of subcutaneous hemor- 
rhage is clearer when associated with profuse hemorrhages in other 
portions of the body, and when there is also a history of the occur- 

9 



130 GENERAL DIAGNOSIS. 

rence of such hemorrhages in the family. Haemophilia is a constitu- 
tional affection characterized by bleeding, which is spontaneous or 
occurs upon slight injury. It is nearly always hereditary, but may 
arise de novo. 

Males are very much more liable to it than females, the ratio being 
about 11 to 1. This curious disposition to bleeding maybe transmitted 
for generations, and almost always to the males through the female 
members of the family — that is to say, the daughter of a bleeder is not 
usually affected, but she transmits the tendency to her sons, who 
become bleeders ; so, too, the granddaughters are not bleeders, but they 
in turn transmit the disposition to their male offspring. It generally 
shows itself early in life, usually before the end of the second year, and 
almost invariably by puberty. 

The affection usually first declares itself by the occurrence of a hem- 
orrhage, either spontaneous or the result of slight injury, the bleeding 
being far more profuse than would be natural, and in some cases abso- 
lutely uncontrollable. 

Legg 1 has divided haemophilia into three degrees, according to the 
severity of the symptoms. The first is characterized by external and 
internal bleedings of every kind, and by joint-affections ; the second, 
by spontaneous hemorrhages from mucous membranes, but no trau- 
matic bleeding or ecchymoses, and no joint-affections ; the third, by a 
tendency simply to ecchymoses. The first form is seen most fre- 
quently in men ; the second most frequently in women ; and the third 
in either sex. 

The most frequent seat of hemorrhage is the nose, and the next the 
gastro-intestinal tract. The bleeding is from the capillaries ; it may 
prove fatal in a few hours, or last for days and weeks with final recov- 
ery. Intense ansemia follows the prolonged hemorrhage, but the blood 
is replaced with remarkable rapidity. All operations, even the most 
trivial, are extremely dangerous in bleeders. Circumcision, extraction 
of teeth, and leeching are credited with the most deaths by Grandidier. 

Joint-symptoms are very common. The knees, elbows, ankles, and 
shoulders are the ones most frequently involved. The attack may be 
marked by pain, redness, swelling, inflammation, and fever ; or fever 
may be absent ; or pain alone may be complained of. The attacks are 
liable to recur, especially in cold, damp weather, and may result in 
stiffened, deformed joints. 

The diagnosis is easy when the history of a hereditary tendency to 
bleed can be obtained. Osier 2 properly remarks that slight joint-trouble 
and petechia? are as much a manifestation of the disease as the more 
severe hemorrhages. In cases in which no history can be secured 
the diagnosis is made by noting a persistent liability to hemorrhage, 
without adequate cause, and associated with joint-affections. 

Osier gives the following excellent summary of the affections with 
which haemophilia can be confounded : 

1. The umbilical hemorrhages of infants, due to jaundice or to syph- 
ilis, hemorrhagica neonatorum, etc. 

1 Haemophilia. London, 1892. 

2 Quoted by Osier, Pepper's System of Medicine, 1885, iii. 932. 



THE DATA OBTAINED BY OBSERVATION. 131 

2. Purpura simplex, often seen in debilitated, rarely in healthy chil- 
dren, usually confined to the legs, and in some cases associated with 
rheumatic pains or swellings in the knees and ankles. 

3. Peliosis rheumatica. 

4. Purpura hemorrhagica, morbus maculosus Werlhofii, a grave 
disease, characterized by extensive cutaneous ecchymoses, mucous hem- 
orrhages, but not dependent on any local disease, or, as far as known, 
on any specific poison. 

5. Infective purpura due to the action of some specific poison — 
smallpox, measles, scarlet fever, cerebro-spinal fever, etc. The hem- 
orrhages may be cutaneous and trivial, or may be in the most aggra- 
vated form of interstitial and mucous bleedings, as seen, for example, 
in black smallpox. 

6. Toxic purpura, as in snake-bites and many poisons, such as phos- 
phorus. 

7. Simple hemorrhagic diathesis, under which may be included those 
cases in which, without any hereditary disposition or previous hemor- 
rhagic history, there is a tendency to uncontrollable hemorrhage from a 
slight wound. 

8. Hsematidrosis, bloody sweats, which occur usually in hysterical 
or epileptic females, and are in rare instances accompanied by mucous 
hemorrhages. 

5. Hemorrhage in Central Nervous Disease. Neuritis. Pur- 
pura in some instances is believed by Mitchell to be due to primary 
disease of the nervous system ; certainly we do see it in neuritis, in 
Raynaud's disease, in myelitis, and in locomotor ataxia. It may occur 
in hysteria, when drops of blood ooze through the skin at the time of 
the attack (hsematidrosis). 

6. Hemorrhage of Toxic Origin. The virus of snakes causes hem- 
orrhages under the skin. In jaundice the blood is disintegrated and 
hemorrhages take place. In malignant types the mucous membrane 
bleeds and sordes collect on the tongue, lips, and gums. To the same 
class belong the subcutaneous hemorrhages that follow the adminis- 
tration of certain drugs, as copaiba, iodide of potassium, quinine, and 
belladonna. (See Medicinal Rashes.) 

Eruptions. 

Diseases of the skin are usually characterized by eruptions. Now, 
such eruptions may be primary and local (from causes operating directly 
on the skin) in the sense that they occur independently of any internal 
affection ; or secondary, the resultant of an internal morbid process. 
The morbid processes are the same, and morbid processes in the skin 
do not differ from such processes in other epithelial structures. The 
anatomical and physiological peculiarity of the part causes the difference 
in the phenomena. Hence ansemias and hyperemias, inflammations, 
acute or chronic, with or without exudation ; hemorrhages, atrophies, and 
hypertrophies, new growths, and parasitic affections are found in both. 
But instead of a painless inflammation with transudation of mucus, as in 
mucous membrane inflammation, we have a more or less painful inflam- 



132 GENERAL DIAGNOSIS. 

mation, with itching (nerve-supply), and with sebaceous and sudorifer-, 
ous gland exudation. Otherwise the same symptoms attend each ; but 
ocular examination of the inner mucous membranes is not possible. 

While the reader is referred to special works on skin diseases for a 
description of the primary or local skin affections, the secondary affec- 
tions will be briefly noted. It must not be forgotten that the local 
affections — eczemas, parasitic disease, etc. — are modified by the general 
conditions or state of health of the patient. 

Clinical Significance. This depends, first, upon the special 
character of the eruption, the nature of the lesion ; second, its distribu- 
tion (a) in the layers of the skin, (6) over the surface of the body ; 
third, its association with other morbid phenomena or various circum- 
stances. 

I. The Nature of the Lesion. Observation concerning the 
nature of the lesion includes (1) its anatomical character, (2) the order 
of appearance, (3) its uniformity, and (4) the mode of invasion. 

A knowledge of anatomical lesions is essential in order to be able to 
define exactly the morbid process and determine the primary cause of 
the lesion. For a long period of time the lesions were divided into 
primary and secondary. The lesions known as scabs, scale, raw sur- 
faces, scratch-marks, and ulcers are always secondary. Scars and 
macular appear latest. The other lesions herein described are primary. 

The writer follows Dr. Pye-Smith in the description of them, as well 
as in most of the matter appertaining to cutaneous affections. 

1. Hypercemia, or congestion. 

a. Mere overfulness of the vessels from paralysis of the vasomotor 
nerves, with redness and heat, but without the exudation and tissue 
changes which accompany inflammation. This hypersemic blush, readily 
produced in the physiological laboratory, is rarely seen as an uncompli- 
cated morbid condition (e. g., Trousseau's tache cerebrate). 

b. Active, arterial, or inflammatory hypercemia, varying in color from 
brilliant scarlet to rose-pink, and combined with heat, tingling, or other 
sensations. 

c. Passive, venous, or congestive hypercemia, dependent upon retarded 
circulation and distended venules. The color is purple, bluish, or livid, 
the surface is cold, and there are no painful sensations. 

2. Pimple, or papule. A small, solid elevation of the skin. 

a. The acute inflammatory papule. 

b. The chronic large inflammatory papule, discrete or confluent. 

c. A solid non-inflammatory papule. 

d. Solid elevations of the skin, which may be called false papules. 

3. Vesicle. A visible cavity in the skin filled with transparent 
liquid. 

4. Pustule. A cutaneous abscess. 

5. Bulla, or bleb. A very large vesicle. 

6. Scab, or crust. A dried-up concretion of the contents of a vesi- 
cle, pustule, or bleb. 

7. 8eaU (squama). A dry flake of epidermic cells. 

8. Wheal (pomphos). A flat, solid elevation of the skin, much larger 
than a papule, and of ephemeral duration. 



THE DA TA OB TAINED B Y OBSER VA TIOK \ 33 

9. Scratch-mark. An injury to the skin, of linear form and curved 
outline. 

10. Raw. A surface which has lost its horny layer of epidermis. 

11. Chap (rima). A crack or fissure which goes through the epi- 
dermis. 

12. Sore (ulcus). The result of destruction by inflammation, which 
has reached below the Malpighian layer and has destroyed the papilla?. 

13. Scar (cicatrix). The result of the healing process after an injury 
or disease deep enough to destroy the papillae of the part. 

14. Nodule. A solid elevation of the skin larger than a papule and 
seated in its deep layer. 

15. Stain (macula). A patch of increased pigmentation of the skin. 

16. Hemorrhage (ecchymosis). When a bloodvessel of the cutis vera 
gives way a dark-red or purple mark is produced, which (like the 
macula) does not disappear on pressure. 

The recognition of the exact anatomical lesion is not sufficient for 
diagnosis unless the mode of invasion is observed at the same time. 
The rash often spreads from a single focus, or numerous foci appear 
and coalesce. The lesion is best studied in the most recent part. Not 
only is the mode of local invasion to be noted, but also the uniformity of 
the anatomical lesion. Often, instead of a simple lesion, various kinds are 
present at the same time, or they develop in successive order ; thus, in 
smallpox, we have first the papule, then the vesicle, and finally the pustule. 

II. Distribution. The location of the lesion in the various layers of 
the skin, and the distribution over the surface of the body, must be 
observed. The layers of shin : (1) The horny layer of the epidermis 
manifests the pathological changes of hypertrophy, atrophy, dryness, 
or desquamation of the cuticle. Dead scales result, in addition to the 
hypertrophies and atrophies indicated in the outline. (2) The eruption 
in a large number of cases is limited to the living Malpighian layer of 
the epidermis and to the papillary layer of the cutis. The hyperemias 
(erythemata), and inflammations of all kinds, are confined to these 
layers. In this situation they never leave scars. (3) The deep layer 
of the cutis is so intimately connected with the subcutaneous tissue that 
morbid changes in it involve the latter, and even extend more deeply. 
The affections are more severe, but less numerous than affections of the 
superficial layers, and are always followed by cicatrices. The changes 
in the sweat glands, sebaceous glands, hair, and nails, so far as they 
refer to internal medicine, have been treated in another section. 

Area of distribution : The distribution of the eruption over different 
areas of the body is of great importance in the diagnosis of the various 
erythemata due to exanthems and to morbid conditions of the gastro- 
intestinal tract. It will be noted more in detail when the specific erup- 
tions are considered. The student should also bear in mind the rela- 
tionship of eruptions or cutaneous changes of nutrition (trophic disor- 
ders) to the affected nerve-supplies. 

III. Associate Morbid Phenomena. The student of internal 
medicine should particularly observe the associated morbid phenomena, 
or concomitant circumstances, in order to determine the nature of the 
skin affection, which may be the expression of internal disorder. The 



134 GENERAL DIAGNOSIS. 

associated morbid phenomena of diagnostic significance are fever, jaun- 
dice, albuminuria, and the phenomena of past or present syphilitic dis- 
ease, tuberculosis, rheumatism, or the rheumatic habit. The presence of 
one of these processes or diseases points to particular affections. Thus, 
a large number of eruptions is attended with fever ; another group is 
of frequent occurrence in the course of rheumatism ; another class 
belongs to syphilis, while a fourth class is associated with anaemia, jaun- 
dice, or albuminuria. This subdivision is not based on the nature of 
the eruption but on its association with other phenomena. It will be 
learned later that all the groups belong to the hemorrhages or the ery- 
themata. The true relationship of the two classes of phenomena can be 
fully ascertained only by inquiry into the history and course of the erup- 
tion and, in addition, into the concomitant phenomena. Thus, if the 
eruption is thought to be due to the exanthemata, the period of incuba- 
tion, mode of infection, symptoms of the invasion, and the progress of 
the attack must be inquired into. 

General Symptoms. In order to determine accurately the cause of 
an eruption and appreciate its diagnostic significance, the general health 
must be inquired into, the condition of the stomach and bowels and 
the character of the urine must be ascertained. It must be remembered 
that local skin disorders are influenced, for good or ill, by the general 
health. Functional disorders of the stomach and bowels are a fre- 
quent source of many of the erythemas, while in diabetes pruritus and 
forms of dermatitis are of common occurrence. The latter are also ob- 
served in Bright' s disease. The cause for the eruption is the same in 
both, in all probability — that is, a perverted secretion of the skin, or, 
if oedema is present, impaired nutrition of the surface. 

The subjective symptoms are of great importance in the attempt 
to ascertain the true nature of an eruption. Pain, itching, burning, 
smarting, and tenderness are significant of the inflammations. Pain 
due to inflammation is constant and smarting, burning or throbbing in 
character. Sometimes, however, pains of a neuralgic character, inter- 
mittent and distributed in the course of nerve- trunks, precede the 
development of eruption. This is seen in herpes zoster. Itching is an 
important symptom in disease of the skin. It is not present in the 
eruption due to the exanthemata generally, except in smallpox, chicken- 
pox, and rubella. Its absence is a striking peculiarity of the erup- 
tions of syphilis ; but in erythema, especially if associated with oedema, 
it is a most annoying symptom. In other skin diseases, as eczema, 
psoriasis, and the parasitic affections, it is much more common and of 
extreme annoyance. 

Itching may be present without any anatomical evidence of skin 
disease. It is seen in the troublesome pruritus that occurs in the aged, 
particularly about the intestinal and genito-urinary orifices, symptom- 
atic of affections of the organs related thereto. It is a symptom which 
should lead to an examination of the urine, as diabetes is sometimes 
found to be the fundamental source of the complaint. It has been pre- 
viously noted that itching occurs to a high degree in jaundice. It is 
also due to the internal administration of drugs, as opium and mor- 
phine, and sometimes quinine. 



THE DATA OBTAINED BY OBSERVATION. 135 

In addition to the associate pathological phenomena which should be 
ascertained in the study of skin eruptions, in order to determine their 
relationship to internal affections, other circumstances should be inquired 
into, such as the occupation, the character of the clothing, degree of 
cleanliness of the patient ; the effects of climate, the season, tempera- 
ture, and the state of the air. 

The following very concise outline, taken from the Avork of the above- 
named author, to whom the writer is indebted for much of the data 
of this section, is here given to enable the student to appreciate more 
thoroughly the pathological relations of the various skin diseases. The 
table also shows at once the relation of the eruptions to the internal 
disorders which concern us more particularly in this work : 

Diseases or the Skin Kegarded as Physiological Processes. 
( Pathological Arrangement. \ 

Acute Inflammations. — Diffuse, e. g., scarlatina, morbilli, syphilis, roseola (eruptive 
fevers, erythema). 

With venous congestion — Erythema nodosum (rheumatism). 

With oedema — Urticaria, erythema nodosum (gastro-intestinal disorder and rheu- 
matism). 

With necrosis — Furunculus, anthrax (diabetes). 

Localized in papules — Enterica (erythemata), syphilis, eczema, prurigo. 

Localized in vesicles — Eczema, zona, variola, scabies, herpes, varicella (eruptive 
fevers, infectious diseases). 

Localized in pustules— Impetigo, variola, scabies, syphilis, sycosis, acne. 

Localized in blebs — Pemphigus, scabies, rupia. 

Desquamating during involution — Scarlatina, etc. 

Chronic Inflammations. — With venous congestion — Acne rosacea, pernio. 

With over-production of epidermis— Psoriasis, pityriasis rubra. 

With oedema — Elephantiasis. 

With fatty degeneration — Xanthelasma. 

With hypertrophy — Elephantiasis. 

With cicatrization — Cheloid. 

With ulceration — Lupus, syphilis, lepra. 

New growths — Xanthelasma, lupus, lepra, syphilis, cancer. 

Atrophy— The senile skin, linae gravidarum. 

Hypertrophy — Ichthyosis, cornu cutaneum, clavis, verruca. 

Hemorrhage — Traumatic (e. g., flea bites), typhus, scurvy. 

Pigmentation — Syphilitic maculae, melasma, chloasma, icterus, ephelis. 

Congenital malformations — Ichthyosis, cutaneous nsevus. 

Neurosis— Pruritus (diabetes, jaundice). 

Anomalies of Secretion. — Increased, diminished, or perverted — Seborrhcea, xeroderma, 
hyperidrosis, anidrosis, chromidrosis, etc. Obstructed — Comedo, milium, acne, 
sudamina. 

A glance at the above outline will show that the eruptions which 
particularly concern us belong to the class of diseases to which the term 
erythema is applied. 

Erythema. Classification. Erythemata may be divided, in 
accordance with the classification of Kaposi, into acute, contagious, 
exudative dermatoses, represented by measles, scarlatina, rubella, and 



136 GENERAL DIAGNOSIS. . 

smallpox ; and the acute, non-contagious, inflammatory dermatoses, 
which may be further subdivided into : (1) typical forms, idiopathic and 
toxic, including urticaria, or nettle-rash ; (2) varieties of herpes ; (3) 
erythemas due to boils, colds, or erysipelas. The first group of the 
?io?i-contagious form includes the class which should always be consid- 
ered in connection with the diagnosis of fevers. The skin inflamma- 
tions closely simulate in their symptoms the eruptive fevers, even to 
the affections of the mucous membranes. Besnier has named them the 
jjseudo-exanthems, and divides them into rubeloids and scarlatinoids. 
Both simulate eruptive fevers throughout their course, and hence both 
are acute and febrile. The scarlatiniform erythemas are febrile at the 
beginning, subacute m course, but of longer duration than the fever 
they simulate. They are the most common forms, and arise from in- 
fectious diseases, such as puerperal fever, septicaemia, and gonorrhoea, 
or from toxaemia due to drugs or articles of food. 

Character of eruption in the non-contagious forms. The ery- 
themata are characterized by (a) rose rash with injection of the surface, 
either (b) with general oedema, or with circumscribed local oedema, 
forming wheals or with papules. In rare cases bullae are also formed. 
(c) The rash is followed by a branny desquamation, (d) The exuda- 
tion that attends the lesion is always watery, in contradistinction to the 
sero-purulent or purulent exudation of eczema and scabies. Sometimes 
slight hemorrhages attend the lesion, as in cases of purpura or of urti- 
caria, (e) The course of the erythema is of diagnostic significance. It 
begins quickly, and is usually attended with febrile symptoms, some- 
times mild, again very intense. (/) The duration is short ; at least it 
is not indefinite. The erythemas that are recurrent must not be con- 
sidered to be one process of long duration, (g) The locality of the 
erythema is not of precise diagnostic significance. The eruption is 
usually symmetrical, and the favorite localities may be defined as the 
extensor surfaces of the forearms and leg, the face, cheeks, neck, and 
the chest and abdomen. True erythema does not attack the scalp, the 
flexures of the joints, the palms (except erythema multiforme), nor the 
soles. (A) The local symptoms that attend erythemata are mild. Local 
tenderness is more marked than in eczema. Smarting and tingling 
are complained of, but severe pain and excessive itching are rare. Only 
when wheals are present do we find pruritus. The rash of erythema 
does not spread. Patches occasionally unite, but an affected area never 
enlarges its borders. 

The etiology of erythema is involved in obscurity. Although 
the frequent associate phenomena are not of etiological, they are cer- 
tainly of diagnostic significance. We may have them occur under the 
following circumstances : 1. In one class the eruption is symptom- 
atic, depending upon dyspepsia or upon rheumatic fever. 2. In the 
eruptive fevers, especially scarlatina and measles, in enteric fever and 
cholera, and in syphilis, there is an early erythema preceding the later 
true eruption. 3. The most striking instance of the relationship to 
internal disorder is seen in the rash that arises after the administration 
of medicine, as copaiba, or after the taking of certain foods. 4. The 
erythemata occur most commonly in children and young people. 



THE DATA OBTAINED BY OBSERVATION. J 37 

They are very frequent in men. The age at which they occur coincides 
with that of rheumatism. 

Varieties of non-contagious erythemata : First, erythema multi- 
forme in simple form, with papules or with exudation ; it may disap- 
pear in a few hours, or persist for a day or two and form rings {ery- 
thema fug ax or erythema annulatum). With the fading of the redness 
faint desquamation ensues, and there may be a few pigment marks. 
The annular form is observed in rheumatic fever. In addition to 
rheumatism erythema multiforme may be found associated with the 
following affections : Typhoid fever, puerperal fever, gonorrhoea, 
cholera, infectious endocarditis and osteomyelitis, syphilis, leprosy, 
vaccination, and surgical septicaemia. Osier has called attention to the 
visceral complications of erythema exudativa multiforme associated with 
the skin lesions — viz., gastro-intestinal crises, endocarditis, pericarditis, 
acute nephritis, and hemorrhage from the mucous surfaces. Arthritis 
is also seen in some instances. The skin lesions range from simple 
purpura to local oedema, and from urticaria to large infiltrating hemor- 
rhages of the skin and subcutaneous tissues. The gastro-intestinal 
crises are attended by colic, with vomiting and diarrhoea. 

Erythema l^ve often appears upon the tense skin of dropsical 
parts. It may be the result of acupuncture. 

Vesicular and Bullous Erythema. To this class belong the 
affections known as herpes and erythema bullosum. 

Herpes zoster is seen in the cutaneous distribution of one or more 
nerves. It consists of vesicles of flattened form, ranged in clusters of 
twenty or thirty, lying on a reddened, slightly swollen bed of skin. 
The number of clusters varies from one to ten. The vesicles develop 
in quick succession, beginning usually near the roots of the nerve whose 
branches they follow. A short papular stage precedes the vesicles, and 
some of the vesicles abort. The eruption tends to dry up in five or six 
days. The crusts form in yellowish or brownish clusters, which fall 
off in the third week, leaving purple stains. 

When the disease attacks the face it follows the course of the fifth 
nerve. The several twigs of the trifacial are traced out from their 
points of emergence from the bony canals. Great swelling of the eye- 
lids sometimes takes place on account of the loose tissue, so that the 
lesion may be mistaken for erysipelas. Ulceration of the cornea and 
iris sometimes occurs, and, when lower divisions of the trifacial are 
affected, vesicles may appear in the mucous membrane of the mouth 
and palate. The cervical nerves and those of the upper extremity are 
also affected in their distribution. The eruption on the arm rarely 
goes below the elbow. When the second and third intercostal nerves 
are affected the intercostohumeral branch produces an eruption down 
the inner side of the arm. The eruption occurs frequently on the 
trunk. Following the course of the dorsal nerves it slants downward 
as it approaches the pubes. 

In the distribution of the disease in the lower limbs the eruption 
rarely extends below the knee or buttocks. It follows the course of 
the external cutaneous or anterior crural nerves, or that of the small 
sciatic. Some of the branches of the sacral nerves are also affected. 



138 GENERAL DIAGNOSIS. 

The disease is unilateral, and its precise limitation to one-half of the 
body is of the greatest diagnostic significance. 

While fever or general symptoms do not usually attend its course 
in any marked degree, insomnia and depression are likely to occur, 
probably on account of the severe neuralgic pain. Pain is the most 
important subjective symptom. It is localized in the nerves, in the 
distribution of which the eruption takes place. It is not so likely to 
be present in the young. The pain may precede the eruption by 
several days, and persist long after the eruption subsides. This is 
particularly the case in old people. 

Herpes labialis, or facialis, consists of vesicles arranged in 
groups or clusters upon an inflamed surface. They appear very sud- 
denly upon the upper lid or the alse of the nose, sometimes on the 
cheek or chin, and they may appear inside the mouth. They undergo 
some changes, as in herpes zoster, but are not attended by severe 
neuralgic pain. They are also symptomatic of an internal disorder, 
an acute catarrh (cold), or follow a rigor, as in intermittent fever or 
pneumonia. They may be present in epidemic cerebro-spinal menin- 
gitis, but are never present in tuberculous meningitis. Diagnosis of 
the former disease is confirmed by their presence (Klemperer). Herpes 
iris and herpes preputialis have no diagnostic significance of internal 
disease. 

Erythema Nodosum. With the erythema there is great oedema. 
The spots are somewhat painful and tender, but do not itch. The 
redness of the erythema is modified by the hue of venous congestion. 
Small hemorrhages may be seen. The patches develop on the legs, 
their long diameter being parallel to the tibia. They rise slowly into 
hard masses. They may be seen on the ankles or the calf, and some- 
times on the ulna. They occur frequently in those who have suffered 
from rheumatic fever. 

Urticaria is a form of erythema in which wheals, sometimes sur- 
rounded by an erythematous blush, are seen. It is an acute inflamma- 
tory oedema of the cutis. The serous exudation fills the lymph-spaces 
and expels blood from the venules. It takes place suddenly, and may 
be excited by chemical irritation or a mechanical irritant, as the finger 
drawn across the skin. Small patches, or large white areas, are seen, 
due to the coalescence of smaller ones (giant urticaria). All parts of 
the body may be affected, except the scalp, face, and soles of the feet. 
The eruption is not symmetrical. Its course may be acute, or it may 
be chronic and transitory, characterized by successive attacks. It is 
the form of erythema in which intense itching is the most pronounced 
symptom. There are no other subjective symptoms. The itGhing 
causes restlessness and loss of sleep. Urticaria is symptomatic of gas- 
tric or intestinal disturbance, or the ingestion of drugs or poisons. 
Another form follows the tapping of a hydatid cyst. It occurs some- 
times in women at each menstrual period, and may be traced to ovarian 
disorder. It may occur after severe shock to the nervous system, with 
high fever. It is not an infrequent complication of rheumatic fever. 
It occurs in men and women equally, but is most frequent in children 
and adolescents. 



THE DATA OBTAINED BY OBSERVATION. 139 

Medicinal Rashes. To the erythemata belong most of the so-called 
medicinal rashes. 

The following drugs are known to cause erythema : potassium bro- 
mide and iodide, copaiba, cubebs, the essential oils, capsicum, santonin, 
chloral, opium, morphine, antipyrin, salicylic acid and its compounds, 
iodoform, belladonna and atropine, tar, carbolic acid, arsenic, cannabis 
indica, digitalis, mercury, silver, copper, and antitoxin. 

Belladonna produces in susceptible persons, or when administered 
in poisonous doses, a diffuse, bright-red erythema, closely resembling 
that of scarlet fever, but without the darker red points which interrupt 
the latter. Atropine also produces in some persons, especially on the 
shoulders, arms, chest, and face, an eruption of disseminated, small, 
hard vesico-papules, showing no tendency to pustulation. They are 
seated on an inflammatory base, but are more superficial than acne. 

The bromides produce a characteristic pustular eruption which is 
most intense upon the shoulders, face, chest, and arms. Large doses, 
or long-continued administration, are generally required to bring it 
out. It is conspicuous upon the face of some epileptics. 

The iodides produce an eruption which is not often pustular, but 
an erythematous or papular rash is not uncommon. It appears chiefly 
about the forearms, face, and neck. Vesicles, bulla?, and purpuric 
spots are also occasionally seen. 

The eruption produced by quinine is generally erythematous, and is 
attended with itching and burning ; the face and neck are attacked 
first. 

Opium and its alkaloid also produce, in susceptible persons, an 
erythematous scarlatinoid eruption which is accompanied by intense 
itching. Itching, especially about the nose, is much more common 
without eruption. 

Copaiba produces a vesico-papular or papular eruption which resem- 
bles urticaria and erythema multiforme. It is itchy. It is more apt 
to be seen on the extremities. It may be purpuric. 

The eruption of cubebs is a diffused erythema, with millet-sized 
papules, coalescent here and there. Unlike the eruption of copaiba, 
it is more copious over the face and trunk than over the extremities. 

Antipyrin causes a measles-like or urticaria-like eruption. 

Erythemata of Infectious Diseases. 

The inflammations of the skin which are symptomatic of a specific 
infection are also of an erythematous variety. The term exanthemata 
has been applied to the latter, but the eruptions of typhus and typhoid 
(enterica) belong to the same class. The characteristics and distinc- 
tions of the various forms will be described in sections devoted to the 
respective diseases. The student should remember the associate general 
phenomena, particularly fever, the onset and the course of which should 
be carefully observed. 

Roseola. Roseola is of a deep rose-color, not arranged hi crescentic 
patches, as in measles, nor scarlet and capable of being resolved into 
innumerable red points, as in scarlatina. It is not so diffuse as the 



140 GENERAL DIAGNOSIS. 

latter. It precedes smallpox, scarlatina, measles, cholera, typhoid fever r 
syphilis, diphtheria, and malaria. In smallpox, in cases of cholera, and 
after parturition and surgical operations, the rash is copious, but is 
characterized by being seated over the lower half of the abdomen and 
the anterior and inner aspects of the thighs. It may appear elsewhere, 
but is usually confined to that portion of the body. 

The erythema of roseola may be mistaken for rubella, measles, or 
scarlatina. The following are points of distinction : First, it is neither 
contagious nor epidemic ; second, there are no prodromal symptoms ;. 
third, the rash does not come out after a definite period of fever ; fourth, 
it is not confined to any special locality ; fifth, the fever is of short 
duration and moderate degree, rarely above 101°; sixth, there is no 
catarrhal discharge from the eyes or nose or in the pharynx ; the fauces 
and palate are reddened without swelling ; seventh, it is not seen in 
the mouth, like the eruptions of measles or scarlatina ; eighth, if pres- 
ent, the fever which precedes the eruption is of only a few hours 7 dura- 
tion (in scarlatina it lasts twenty-four hours, in measles seventy-two 
hours) ; ninth, the rash is not crescentic as in measles, nor punctiform 
as in scarlatina, though it must be admitted that severe cases of the 
affection cannot be easily diagnosticated, the development of the sequelae 
alone concluding the diagnosis. 

To add to the confusion, an erythema called roseola often precedes 
the eruption of a particular fever. The association with this class of 
fevers has been indicated before. 

Sufficient reference has been made to the erythemata that attend rheu- 
matism. A few other internal (infectious) disorders are associated with 
the development of an eruption. In cholera y during the period of reac- 
tion, a rose rash which may resemble erythema, urticaria, or scarlatina 
appears coincidently with a rise of temperature. It is most frequently 
seen on the forearms and backs of the hands, but may cover the back 
and limbs. It may be slightly hemorrhagic and last two or three days. 
A slight desquamation usually follows. In influenza a roseolous erup- 
tion, covering the trunks and limbs and becoming papular, is seen in 
rare cases. 

In addition, erythematous eruptions are sometimes seen in the course 
of Bright's disease. Two forms, quite distinct from the previously 
mentioned erythema lseve, are observed : the roseola on the feet, legs, 
and hands — rarely on the chest and abdomen ; and the papular form 
on the thighs, arms, and shoulders. Itching and other subjective 
symptoms do not attend the eruption. A form with desquamation 
may begin on the limbs. These erythemata are common in the later 
stages of Bright's disease, but are not of ill omen. In acute Bright's 
disease a transient roseola is observed very rarely ; so also is purpura. 
If there is much anasarca in tubal nephritis, erythema is more common. 
The eruptions usually appear independently of ursemic symptoms, and 
disappear during their continuance. They are in all probability allied 
with the inflammation which attacks the lungs and serous membranes 
in Bright's disease. 

Sudamina. Here may be mentioned another eruption, or condition 
of skin, common in the course of internal diseases. Sudamina, or 



THE DATA OBTAINED BY OBSERVATION. 141 

miliaria, are small, clear vesicles seen in large numbers, usually on the 
abdomen, but also on any other part which reflects the light strongly. 
They are seen during and after the subsidence of profuse sweats. 
While actual perspiration is seen on the forehead, the trunk may 
appear free from moisture. When the hand is placed over it, as on 
the abdomen, the dryness is noted, but at the same time a roughened, 
nutmeg-grater-like sensation is felt. On close inspection this is ob- 
served to be due to the eruption just mentioned. The vesicles are 
usually of good prognostic omen in the course of febrile diseases, par- 
ticularly typhoid fever. They are due to the accumulation of perspi- 
ration under the epidermis. 



General Diagnosis of Skin Affections. 

(Condensed from Pye-Smith.) 

I. Factitious Eruptions. We must never forget the possibility of 
the affection before us being artificial. All kinds of dermatites, eczema, 
erysipelas, pemphigus, impetigo, may be simulated by the application 
of various irritants. Pigmentation also has often been imitated with 
success. Such artificial lesions will generally be found upon the arms, 
rarely on the face, and scarcely ever beyond reach of the patient's 
hands. Mustard, cantharides, and some other irritants can be distin- 
guished with the aid of the microscope. 

II. Traumatic Eruptions. In all cases of dermatitis we should 
seek for the irritant, and sometimes it is so directly the cause of the 
disease that the eczema or impetigo in question may be considered 
purely traumatic, and efficient treatment immediately follows accurate 
diagnosis : sublata causa tollitur effectus. 

Pediculi in the hair should be carefully looked for in all cases of 
impetigo in children ; pediculi vestimentorum in prurigo of old people. 
The acarus of scabies, fleas, bugs, and gnats may be found. In adults, 
pediculi pubis may sometimes be found in the axillae as well as in their 
proper region, and when they have been destroyed by mercurial oint- 
ment the patient is at once relieved from pruritus. 

Frequently the irritant must be sought for in the objects which the 
patient habitually handles. The coarser kinds of brown sugar are a 
frequent cause of eczema of the hands (grocer's itch). So with many 
of the " chemicals " used in a variety of modern handicrafts. Constant 
washing of the hands in washerwomen, in scrubbers, in potmen, and 
many others produces eczema rimosum. The heat of the sun is the 
cause of eczema solare and ephelides ; the heat of the fire, of the pig- 
ment spots on the shins of elderly people. Sweat, again, is a very 
common irritant, producing the erythema which usually accompanies 
sudamina and also intertrigo of opposed surfaces. Scratching, as a 
cause of traumatic dermatitis, has been repeatedly referred to. 

III. Febrile Rashes. We must never forget that a cutaneous 
eruption may possibly be part of an acute exanthem. The use of a 
clinical thermometer is a great help in this respect. Variola is fre- 
quently mistaken for syphilis and other affections. 



142 GENERAL DIAGNOSIS. 

IV. Medicinal Rashes. Other cases are due to certain kinds of 
food or to drugs. They have been described above. 

V. Syphilodermata. When we have satisfied ourselves that the 
eruption before us is not factitious, nor directly traumatic, nor a symp- 
tomatic eruption, we may next consider whether or not it is due to 
syphilis. In this inquiry it is undesirable to ask questions the answers 
to which are as apt to mislead as to guide aright. 

1. We should first consider the color of the affected skin, remember- 
ing, however, that the pigmentation which gives the so-called coppery 
or raw-ham tint to a syphilitic eruption is the same which is sooner or 
later produced by all forms of dermatitis. Psoriasis, chronic eczema, 
lichen planus, and prurigo may all produce shades which bear the 
closest resemblance to syphiloderma. 

2. The lesions of syphilis are multiform. It is rare in any but 
syphilitic affections to find mere hyperemia in one part and associated 
pustules, papules, scales, or ulcers in others; and it is not often that a 
syphilitic eruption exhibits only a single elementary lesion. 

A pustular eruption in an adult should always suggest the question 
of syphilis when that of scabies has been answered in the negative. 

3. Syphilitic eruptions, for some unknown reason, do not itch — the 
exceptions to this rule are remarkably few; they usually occur during 
the stage of scabbing of pustular rashes or during the healing of 
tertiary ulcers. An ordinary secondary syphilide may, however, as a 
rare exception, be so irritating that wheals and scratch-marks are 
present. On the other hand, psoriasis is often free from irritation, 
while the degree of itching of eczema, and even of scabies and prurigo, 
varies greatly. 

4. The local distribution of syphilitic disease is a great aid in diag- 
nosis. Specific eruptions are certainly not, as a rule, symmetrical; the 
early roseolous rash is only so because it is general, and therefore, upon 
a surface like the human body, more or less symmetrical. Moreover, as 
it chiefly affects the face, chest, and trunk generally, it is near the 
middle line. But we do not see symmetrical patches of syphilide in 
corresponding parts of both sides of the face, both sides of the trunk, 
or the right and left limbs. In all but the earliest syphilides the 
affected patches are very decidedly and constantly un symmetrical, 
irregularly scattered over head, trunk, and limbs, and chiefly remark- 
able for having no well-marked seats of predilection. 

The forehead, especially about the roots of the hair, is, however, 
very frequently the seat both of the early and middle erythematous, 
scaly, and pustular syphilides, and the palms of the hands and soles of 
the feet are frequently symmetrically affected with the later scaly eruption. 

Practically, when we find a disease of the skin occupying some un- 
usual position, we should at least consider the question of syphilitic 
origin. 

5. These signs, alone or in combination, serve to distinguish early 
specific roseola from erythema, eczema, scarlatina, and measles, and the 
later eruptions from eczema, lichen, impetigo, and psoriasis. 

The eruptions of congenital syphilis which are most liable to be mis- 
taken are : The so-called pemphigus of infants, which is known by its 



THE DATA OBTAINED BY OBSERVATION. 143 

affecting the palms and soles ; rupia, which, by the form of the crusts 
and the ulcerated surface beneath, may always be distinguished from 
impetigo ; an erythematous rash of the nates and genitals of infants, 
which is distinguished from eczema of the same parts, also common at 
that age, by its coppery color, its blotchy distribution, and more clearly 
denned margin. 

The tertiary ulcers of syphilis are distinguished by their presence in 
unusual places, by their punched-out edges, circular or so-called horseshoe 
shape, and by the fact that they usually give little pain or discomfort. 

Tertiary ulcers have no predilection for the outer side of the leg, but, 
inasmuch as the part above the inner malleolus is, from anatomical 
causes, the chosen seat of varicose ulcers, most ulcers in the first posi- 
tion will be syphilitic and in the latter not. Moreover, the age helps 
in the diagnosis, as varicose ulcers rarely occur before the fortieth year. 

Most ulcers on the arms are found to be tertiary syphilitic ulcers. 

VI. Tineae. The next group of skin diseases includes those which 
are due to vegetable parasites — tinea versicolor of the trunk, eczema 
marginatum of the perineum and thighs, tinea circinata of the neck 
and other parts, tinea sycosis of the chin, and tinea tonsurans of the 
scalp. In all doubtful cases the microscope should be employed. 

Tinea of the scalp is rare in adults, and tinea circinata still more so ; 
tinea marginata occurs only in adult males. 

VII. Primary Superficial Inflammations. To distinguish the 
superficial from the deeper kinds of dermatitis, we should notice 
whether the cutis alone is infiltrated and thickened, or whether it is 
bound down by adhesions to the subcutaneous tissues. The presence 
of scars, however slight, is a proof that the process has gone deeper 
than the papillae, and has more or less extensively destroyed the papil- 
lary layer. Superficial inflammations, excluding those due to acarus, 
to pediculi, and to other direct irritants, and excluding also those which 
are the result of vegetable parasites and of syphilis, fall, with respect 
to their treatment, into three large groups : 

The first group, represented by impetigo and most forms of eczema, 
consists of inflammations which are subacute, and accompanied with 
burning, itching, and pain, sometimes with a slight degree of fever. 

The second group of superficial inflammations of the skin is typically 
represented by psoriasis, but includes lichen planus, the more chronic, 
dry, and obstinate forms of eczema, and true prurigo. These affec- 
tions are chronic, with little irritation, exudation, pain, or active signs. 

The third group is that of erythemata. 

VIII. The Acne Group. Acne, both in its pathology and etiol- 
ogy, differs from other forms of dermatitis. The age of the patient 
and its distribution are sufficient for diagnosis. It is at once a super- 
ficial and a deep dermatitis, and is often followed by scars. Its treat- 
ment consists entirely, or almost entirely, in local applications directed 
to the correction of the sebaceous affection. With acne may be classed 
sycosis and furunculus. 

IX. Deep Affections. When we have ascertained that the affection 
of the skin is deep, that is to say, that it goes below the papillary layer, 
the field of diagnosis is limited. 



144 GENERAL DIAGNOSIS. 

Excluding erysipelas, which is distinguished by its acute character 
and febrile symptoms, excluding the pustular affections which affect 
the skin deeply and produce scars only at isolated points, such as acne, 
variola, and herpes zoster, and excluding, thirdly, leprosy and other 
exotic diseases, we have to distinguish in the great majority of cases 
which come before us in this country — first, traumatic and varicose 
ulcers ; second, gummata and syphilitic ulcers ; third, lupus ; fourth, 
rodent ulcer ; and fifth, carcinoma of the skin. 

With regard to the first of these, we must not assume, because a sore 
upon the skin is said to be the result of a blow or a kick, that it is 
purely traumatic, for syphilitic ulcers often arise in this way. Malig- 
nant ulcers are rare, and are usually obvious from the age of the 
patient, the pain they occasion, their tumid margins, and their blood- 
stained secretions. Moreover, they are, with few exceptions, confined 
to the neighborhood of the orifices of the body, especially the lower 
lip, the urethra, the vulva, and the anus. Rodent ulcer, however, is 
very difficult to diagnose with certainty. Its locality, its slow and 
painless progress, and its belonging to the latter half of life, usually 
serve to distinguish it from lupus ; and its being single, excessively 
chronic, and unaccompanied by nodes or other syphilitic lesions, are 
the best characteristics for diagnosis from a tertiary ulcer. 

The Nutrition of the Skin. 

Palpation. The color, as determined by inspection, is a fair index 
of the nutrition of the skin, but further information is obtained by pal- 
pation. In health the skin is smooth, firm, and elastic. When pinched 
between the thumb and fingers and then allowed to escape, it slips 
quickly back into its former position. When pressed or squeezed, it 
becomes pale from expression of blood, but resumes its natural hue 
immediately. 

The readiness with which the blood returns after pressure shows the 
character of the capillary circulation of the skin. This is active in 
health and sluggish in serious disease of the lungs, heart, and blood- 
vessels. In the eruptive fevers, especially in measles, scarlet fever, 
and smallpox, sluggish capillary circulation with dusky eruption is a 
grave sign. In measles it is usually due to pulmonary complications, 
and in other infectious diseases to the overwhelming effects of the poison. 

As age advances the skin becomes less elastic, and in old persons 
may lie in wrinkles. When pinched between the fingers the skin is 
more inclined to remain wrinkled. Fat persons whose skin is firm 
and hard are in much better condition than those whose skin is loose 
and flabby. The latter condition is frequently met with in babies, 
particularly those that are fed on artificial foods. When the skin is 
thin and dry and loses its tone, so that, when pinched into folds, it 
resumes its smoothness but slowly and sluggishly, it is usually evi- 
dence, in a person under fifty, of some grave cachexia, as carcinoma. 

Moisture and Dryness of the Skin. Moisture and dryness are in 
one sense correlated with the nutrition of the skin. It is quite certain 
that when the skin is abnormally dry its nutrition is impaired. 



THE DATA OBTAINED BY OBSERVATION. H5 

In health the skin is not perceptibly moist, except as the result of 
physical exertion or under heat, or as the immediate result of imbibing 
a hot fluid or a sudorific drug. There is considerable individual differ- 
ence, however, within the limits of the normal. Rheumatic and stru- 
mous persons may have a perceptibly moist and oily skin at all times, 
while others have a skin which perspires very little, even under influ- 
ences which usually bring about perspiration. 

Perspiration Increased. Hyper idrosis. It may be general or 
local. 

A. General increased perspiration is seen — 1. With fever. It occurs 
in the course of rheumatism, when the sweats are strong in odor and 
acid in reaction. It is seen in tuberculosis, especially the miliary 
variety. It is sometimes marked throughout cases of typhoid fever. 
General perspiration also attends the violent muscular action of tetanus, 
but is not seen in epilepsy. An example of general sweating is seen in 
that curious affection to which the term " sweating sickness " has been 
applied. It is a fever the nature of which is not well knowm, but in 
which this symptom is most pronounced. Sweating is extreme in 
trichinosis. 

2. With normal or subnormal temperature, a. Sudden, temporary 
perspiration. Sweats occur from excitement or slight exertion hi 
patients during convalescence. A general profuse perspiration may be 
of short duration and occur suddenly after fright or shock in health. 
It is the characteristic perspiration of collapse. The forehead is cov- 
ered with sweat, large drops stand out on the face, the hands and feet 
are moist or wet with perspiration, and the whole surface of the body 
" leaks. " It is attended by a cold and clammy skin. In the collapse 
of all forms of shock, or after hemorrhage or profuse discharge, as in 
cholera, this form of perspiration is seen. 

More striking still are the perspirations that suddenly break out in 
the course of acute disease coincidently with a fall of temperature. We 
have (1) the critical sweats of pneumonia and relapsing fever ; (2) sweats 
which terminate a paroxysm of intermitting fever, whether of malarial 
or infectious origin (see Fever) ; (3) the profuse perspiration that 
attends pyaemia, breaking out with each fall of temperature to disappear 
as it rises ; (4) the night-sweats that attend tuberculosis and other ex- 
hausting diseases. In tuberculosis and in pus-formation or accumula- 
tion the oscillation of temperature, with or without chills, followed by 
sweating, is knowm as hectic. Sudden breaking out of general per- 
spiration, but more notably seen on the face, attends dyspnoea of pulmo- 
nary origin and the attacks of dyspnoea in the course of organic heart 
disease. These perspirations are at times the result of an effort at 
elimination, on the part of the skin, to relieve the kidneys or bowels, 
such as the perspiration of urcemia, which is attended by a urinous 
odor. At times it may also occur in jaundice. In the conditions just 
mentioned there are coolness of the skin and cold extremities. 

b. Prolonged Perspiration. In exhausting diseases, general and 
persistent perspiration may occur, particularly in the later stages, as in 
tuberculosis, and in any disease attended by persistent dyspnoea. 

10 



146 GENERAL DIAGNOSIS. 

B. Local increased perspiration (hyperidrosis localis) occurs when 
there is local vasomotor paresis. Thus, in organic diseases of the brain 
and in affections of the peripheral nerves, in some forms of neuralgia, 
in migraine and in hysteria, it has been observed. Sometimes one 
side of the body alone is affected, even in a malarial paroxysm (hemi- 
drosis). 

Local sweats are sometimes significant. This is the case particularly 
with a sweat confined to the head, which occurs usually in children, and 
is one of the striking characteristics of rickets. With the local sweat- 
ing the patient rolls his head at night from discomfort. The hair on 
the back of the head is rubbed off. 

Unilateral sweating of the head may arise from destructive pressure 
on the sympathetic nerves, causing paralysis of the dilator fibres of the 
cilio-spinal branches, in thoracic aneurism, and in caries of the lower 
cervical vertebrae. There are usually contraction of the pupil and con- 
gestion of the face on the same side. 

Diminished Perspiration. Anidrosis. The skin is abnormally 
dry in the early stages of acute disease attended by fever, particularly 
if the febrile rise takes place suddenly, as in acute digestive disorders 
of children. In adults, when the disease is accompanied by high fever, 
as in thermic fever, the skin is dry. In the first day of the eruption 
of the exanthemata the dryness is marked. Dryness of the skin is of 
frequent occurrence when there are copious discharges of water from 
the bowels or the kidneys. In choleraic diarrhoea the dryness occurs 
suddenly. In some affections, as diabetes and Bright' s disease, the 
dryness extends over a long period of time, and is frequently attended 
by eruptions or desquamations and by the formation of boils. When 
there are accumulations of serum in the lymph-spaces of the subcu- 
taneous connective tissue, or changes in the connective tissue, as in 
dystrophies or myxoedema, or scleroderma, the skin is dry because of 
the stretching and pressure on the bloodvessels. 

Scars. Scars are important proofs of the occurrence of previous 
disease, especially smallpox, chickenpox, and syphilis. Scars of the 
first two occur in the form of circular pits, and almost always on the 
face. Scars of syphilis are larger, circular, or oval in shape, and seen 
usually to the best advantage on the extremities, but the single scar on 
the forehead is strikingly suggestive. Scars upon the legs in persons 
under thirty years of age, when not traumatic, are almost always 
syphilitic. Scars as the result of suppurating glands are seen most 
frequently in the neck, but may be found wherever there are glands, 
especially under the jaw and in the axilla and groin. They are most 
liable to occur in tuberculous persons, either spontaneously or as the 
result of the exanthemata, erysipelas, or other infectious disease. When 
such scars are met with in a person with incipient tuberculosis the 
prognosis becomes more anxious. 

The appearance of the scar indicates its age in a general way, and 
hence throws light upon the patient's previous history, and also serves 
as a check upon the accuracy of his statements. 

Scars the result of wounds, injuries, or operations may be seen any- 



THE DATA OBTAINED BY OBSERVATION. 147 

where ; they are of importance only so far as they may furnish a clue 
to the cause of existing disease. Of such nature are the scars upon the 
head in cases of brain disease, particularly epilepsy. 

The scars of pregnancy, the striae seen upon the lower part of the 
abdomen and the upper part of the thigh, must not be confounded 
with similar scars that occur in great oedema, and which are some- 
times found in fat persons. They are also seen after typhoid fever. 



CHAPTER XI. 

THE DATA OBTAINED BY OBSEEVATION— {Continued). 

The subcutaneous connective tissue. (Edema — causes — mode of recognition — situation 
— feet, face, arms, and head — oedema of trichinosis — angioneurotic oedema. 
Myxoedema. Connective tissue dystrophies. Scleroderma. Sarcomata — cysti- 
cercus cellulosse — brawny induration. Subcutaneous nodules. The lymphatic 
glands. Enlargements — local — general. Adenitis. Hodgkin 1 s disease. Tuber- 
culosis and leucaemia. 

THE SUBCUTANEOUS CONNECTIVE TISSUE AND 
LYMPHATIC GLANDS. 

Enlargements or swellings of the subcutaneous connective tissue, 
other than the skin tumors and papular eruptions, on any portion of 
the surface of the body, are due to some change in the tissue or the 
structure or organs directly underneath the swollen part. CEdema, 
myxoedema, subcutaneous emphysema, dystrophies, scleroderma, brawny 
induration, and local subcutaneous swellings are the principal ones to 
be considered. 

(Edema; Dropsy. 

The lymph-spaces of the subcutaneous connective tissue become over- 
distended with serum, causing an accumulation to which the general 
term dropsy is applied. If the accumulation is local and confined to 
small areas it is known as oedema. If it is general, and if, in addi- 
tion, the large lymph-cavities, the pleura, the peritoneum, and the 
pericardium contain fluid, it is known as anasarca. Accumulation 
occurs because more fluid is poured out by the vessels than can be 
removed by the lymphatics and veins. This may depend either upon 
obstruction of the veins and lymphatics, or excessive exudation from 
the bloodvessels, or both. The former condition, however, is rare, 
and usually local, because, unless the obstruction is very great, the 
veins and lymphatics are able to carry away more fluid than is effused 
from the capillaries. 

1. Excess of fluid transudes when there is local capillary change 
from inflammation or the effects of poisons. The change must be in 
the capillaries. It was thought that this general process was of an 
inflammatory nature, but at present it is believed to be due to the in- 
fluence of poisons, probably absorbed from the intestinal canal, alter- 
ing the nutrition of the capillary vessels. Thus, the oedema and 
general dropsy of albuminuria, particularly in the early stage of that 
affection, are thought to be due to a poison circulating in the blood 
which also causes the nephritis. Mahomed found a pre-albuminuric 



THE DATA OBTAINED BY OBSERVATION. 149 

stage of scarlet fever, in which he noted a peculiar reaction of the 
urine, which gave a blue color with guaiac. A brisk purgative admin- 
istered when this reaction was noticed would prevent the occurrence of 
albuminuria, whereas if the drug was withheld albuminuria always 
followed. The purgative removed the poison which caused the 
nephritis and oedema. 

It is well known that in urticaria there is marked local oedema. 
Brunton thinks that some poisons circulating in the blood cause paral- 
ysis of the secreting power of the sweat-glands, on account of which 
there is not only effusion from the bloodvessels, but at the same time 
such changes in the secreting-cells take place as to produce an acid, 
the local irritative action of which, upon the capillaries, causes a 
further transudation of fluid. That acids circulating in the blood have 
the power of creating oedema, the experiments of Cash and Brunton 
fully demonstrate. While, therefore, in the oedema of Bright' s disease 
in its earliest stage and in urticaria we have this explanation of the 
phenomena, other factors are causal in other forms of oedema. 

2. Increased transudation and obstruction to the flow of lymph are 
the causes of some forms of oedema. It may be of local origin, as in 
the oedema over the site of an inflammation or the oedema of an arm 
or leg from venous occlusion, or it may be of general origin, as in car- 
diac disease. The obstruction may be in the lymphatics or in the 
veins. In the former it may occur (a) from want of muscular action ; 
(6) from want of inspiratory action of the thorax ; (c) diminution of 
the diastolic suction of the heart ; (d) positive pressure on the veins. 
In the latter, obstruction of the veins is caused by conditions similar to 
those affecting the lymphatics, and arises from (a) want of muscular 
action ; (b) want of movement of the thorax ; and (c) feeble action of 
the heart ; and, in addition, it is likely to be caused by (d) complete 
arrest of blood-flow from external pressure upon the vein or from 
plugging of the vein. It can readily be seen, with a little knowledge 
of physiology, how the above factors favor the development of oedema 
due to disease of the heart and to venous obstruction. The baneful 
factors are those which retard the flow of blood, preventing its return 
to the right heart. Hence it is called the oedema of passive congestion. 

3. A third form of oedema, usually slight, is that which is seen in 
anaemia. Several factors combine to produce it : (a) the watery con- 
dition of the blood ; (b) the condition of the capillaries ; and (c) vaso- 
motor paresis on account of imperfect nutrition of the vasomotor 
centres. It may be diffused, as in the anasarca that attends the 
anaemia of malaria. 

4. GEdema may be of nervous origin. Such is the oedema that 
occurs in diseases or injuries of nerves. To it possibly belongs the 
oedema of beri-beri. It may be a trophoneurosis with secondary alter- 
ations in the permeability of the vascular walls, or it may be due to 
vasomotor paralysis. 

Mode of Recognition. Whether the accumulation is in local areas 
or distends the entire subcutaneous tissue, the oedema is not difficult of 
recognition. The part is swollen and puffy, the surface is pale, smooth, 
and shiny, the temperature is usually low, and the affected area pits 



150 GENERAL DIAGNOSIS. 

on pressure. Pitting is more pronounced if the finger is pressed over 
a part which is seated upon a firm background, as bone. (Edema of 
the ankle or over the tibia is more readily recognized than oedema in 
the calves. 

The oedema obliterates normal depressions and increases the rotundity 
of the affected part. It causes deformity, as of the face and neck 
or of the penis, when the accumulation of serum is considerable. The 
swelling appears in the most dependent parts if the oedema is diffuse 
or the cause is general, as in cardiac disease ; or in parts made up of 
loose connective tissue, as the eyelids or scrotum. The temporary dis- 
appearance of the oedema, either entirely or from one part, to appear 
in another, is a prominent feature of it. It will disappear between 
morning and evening, or its position will alter with change in the posi- 
tion of the body. The presence of a previously existing oedema can 
often be told by the scars or striae that resulted from overstretching of 
the skin, as of the abdomen and thighs. 

(Edema is to be distinguished from — (1) Inflammatory swellings, 
by the absence of the classical signs of inflammation : pain, heat, and 
redness. (2) The enlargement of myxoedema differs from oedema by 
the absence of pitting on pressure, the occurrence of induration, which 
resists the pressure of the finger, and by the occurrence of anaesthesia 
or analgesia. (3) The swellings of connective-tissue dystrophies are 
hard, localized areas that do not pit on pressure, and are not seated in 
dependent parts of the body. They are found on the arm, for instance, 
or on the thigh, or about the flanks and in the axillae. (4) The swell- 
ing of subcutaneous emphysema differs from oedema in that it arises 
in the course of some disease of the air-passages, and, on palpation, the 
crackling sensation of air under the finger is distinctly felt, while there 
is no pitting on pressure. In the cases that the writer has seen the 
parts were particularly tender, although pain in subcutaneous emphy- 
sema is said usually to be absent. 

Diagnostic Significance. The value of oedema as a diagnostic sign 
depends upon its location, its mode of development, and its association 
with disease of other organs or structures of the body. 

Location. The oedema may be limited to small areas, as the eyelids, 
the face, or the feet, or to an arm or leg ; it may involve an arm and 
leg of the same side ; or it may involve the extremities and trunk and 
even include the face. We therefore have local and general oedema. 

Local (Edema. Local oedema occurs when there is pressure on a 
vein or occlusion of it by a thrombus. (Edema of the arm from press- 
ure on the veins by enlarged lymphatic glands in the axilla, and oedema 
of the leg from thrombosis of the femoral vein, are examples of this 
form of local oedema. Dropsy of an arm often occurs when the patient 
has laid upon it. Local oedema also occurs over the seat of inflamma- 
tion, and is a valuable diagnostic sign. It is an indication of suppura- 
tion. It is known as " inflammatory " or " collateral oedema.' 7 It is 
due to obstruction of the lymph circulation. It is seen over the mas- 
toid when its cells are the seat of inflammation ; over the parotid 
gland under the same circumstances ; over parts of the thorax in em- 
pyema ; over the praecordia in purulent pericarditis ; over the surface 



THE DATA OB TA IN ED B Y OBSEB VA TION. 151 

of the liver in some cases of hepatic abscess ; in the abdominal parietes 
in purulent peritonitis, but more marked over the primary focus of in- 
flammation, as the gall-bladder region or the region of the appendix. 

The Arms and Thorax. Another form of local oedema occurs 
when there is pressure upon the superior vena cava from aneurism or 
disease of the mediastinal glands. The oedema is then limited to the 
arms, head, neck, and thorax. Such oedema is usually associated with 
cyanosis of the hands and arms. There is also marked distention of 
the veins of the upper parts of the body. The oedema has been found, 
in a few instances, to be more marked on one side than on the other. 
This has occurred in cases of aneurism which communicated with the 
vena cava. Either the collateral circulation on one side had been 
established or pressure was greater on the left innominate vein. The 
oedema is sometimes limited to the head and arms. If the obstruction 
of the superior cava is situated below the entrance of the azygos vein 
the chest shares in the venous congestion and resulting oedema. If, 
on the other hand, the obstruction is above the azygos vein there is 
no oedema of the chest-wall. This form of oedema, as a rule, is easily 
recognized by the presence of the above-mentioned symptoms, with 
other pressure-symptoms, due to disease of the mediastinum and by 
the results of physical examination, which reveals the presence of a 
tumor in the thorax. It usually develops slowly, hand-in-hand with 
the other symptoms. At times, however, it occurs suddenly. Sudden 
oedema in this situation is always due to an aneurism which has rup- 
tured into the vena cava (see above). The sudden onset is attended 
by physical signs of aneurism, or, if they are not present, by a murmur 
characteristic of the communication between an artery and a vein. It 
must be confessed that often the physical signs are not precise and the 
murmur is absent. The suddenness of the peculiar localized oedema is 
the chief point of diagnosis in favor of this rare form of aneurism. 

The (Edema of Trichinosis. (See Face.) (Edema of the skin over 
the affected muscles, as well as of the face, occurs in trichinosis. It 
begins early in the disease, disappears after a few days, to return again 
later. It is localized over the muscles, and is associated with the 
growth of trichina? in them. It is distinguished from cardiac and 
renal dropsy by its course and situation as well as by the fact that the 
scrotum and labia majora are never oedematous. 

The cause of the above forms of oedema is local and in close prox- 
imity to or in intimate anatomical relation with the dropsical swelling. 
But the cause of local oedema may be central, or in a sense general. 
It then develops gradually and begins in special localities, as in the 
feet or face. 

The Feet. (Edema of the feet or ankles is usually due to disturb- 
ance of the circulation. It arises in heart disease, or in the course of 
any exhausting and debilitating disease in which the heart has become 
weakened. The organic change which takes place in the heart-muscle 
(dilatation) in the course of obstructive valvular disease and in lung 
disease is often attended by oedema of the feet. Later a general dropsy 
may ensue. But oedema of the feet may occur from another cause — 
i. e., anaimia. In all forms of this affection puffin ess of the ankles may 



152 GENERAL DIAGNOSIS. 

be seen. An explanation of the canse has been given. Similar local- 
ized oedema in individuals of relaxed fibre occurs hi the evening after 
a day of considerable physical exertion. (Edema of the feet, subse- 
quently becoming diffuse, occurs in beri-beri. 

(Edema of the Face. (Edema may begin or remain localized in 
the face, and is very striking. (See Face and Eyelids.) It may be 
limited to the eyelids, as a simple puffiness, or may spread over the 
entire face, causing complete obscuration of the normal outlines. It 
is the oedema of renal disease, and differs from oedema of the feet in 




Face of a patient with general anasarca due to chronic parenchymatous nephritis. (Hare.) 

that it is more marked in the morning on rising and disappears toward 
night. Of all forms of local oedema it is the most grave, and should 
at once call attention to the condition of the urine, particularly if the 
patient has just had an attack of scarlatina, or if it occurs in a woman 
who is pregnant. 

The diagnostic significance of primary local oedema may be summar- 
ized as follows : (1) Eyelids or eyes (" Bright " eye, " tear that does not 
fall ") in nephritis; (2) face, nephritis; (3) forehead, trichinosis; (4) 
head, pressure upon superior vena cava above the azygos vein ; (5) one 
side of head, pressure upon innominate vein ; (6) head and arms, or 
head, arms, and thorax, pressure upon superior vena cava ; (7) one 
arm, pressure upon axillary veins ; (8) one leg, pressure upon femoral 
vein ; (9) hothfeet or legs, pressure upon inferior vena cava by abdomi- 
nal tumor, loss of vasomotor tone, heart disease, anaemia, late nephritis ; 
(10) the loins, " lumbar cushion," nephritis, cardiac disease if patient is 
in recumbent posture ; (11) the scrotum, nephritis and cardiac disease ; 



THE DATA OBTAINED BY OBSERVATION. 153 

(12) local oedemas over inflammations of structures underneath, as 
bones, the gall-bladder, the appendix, the pleura, peritoneum, or peri- 
cardium. 

General (Edema. Anasarca. General anasarca is due to heart or 
to kidney disease in most of the cases. (Edema of the face and feet 
may become general. In cases in which the face is first (Edematous its 
extension may be very rapid, so that twenty-four to forty-eight hours 
after the swelling is noticed the whole body is in a state of anasarca. 
Renal disease. The extension of oedema, primarily seated in the feet 
and legs (cardiac dropsy), throughout the rest of the body is more 
gradual, and develops with other signs and symptoms of weakness of 
the heart. Hence cyanosis gradually appears. This may be seen first 
in the extremities. Finally the face and lips take on the peculiar hue. 
On the other hand, in the general anasarca that follows the local 
oedema of the face in Bright' s disease, pallor occurs, and as the oedema 
increases it becomes more and more of a waxy hue, while the extremi- 
ties beome glistening or shining in appearance. In the so-called " wet 
form " of beri-beri general oedema comes on rapidly. 

Angioneurotic (Edema. This curious affection is not of frequent 
occurrence. It may be present in the individuals of several genera- 
tions of a family. The attack conies on suddenly. The swelling is 
circumscribed. It may appear on the face, on the brow, the lips, or 
cheek. The eyelid is a common situation. It may also occur on the 
backs of the hands, the legs, or in the throat. It remains but a short 
time and disappears as quickly as it came on. The outbreaks have 
exhibited distinct periodicity. Local symptoms of itching, heat, or 
redness, or general urticaria, may precede the swelling. The sudden 
swelling causes great deformity. If the upper lip is affected, the 
mouth cannot be opened ; if the hands, the fingers cannot be bent. In 
the hereditary cases the attack recurs every three or four weeks. The 
danger to life is from oedema of the larynx, which caused death in two 
of Osier's cases. The general symptoms that attend the attack are 
gastro-intestinal. Xausea and vomiting occur, followed by severe colic. 

It must not be confounded with simple urticaria, or the giant form of 
that affection, with which it may, however, have close affinities. It is 
regarded by Quincke as a vasomotor neurosis, which leads to impair- 
ment of the permeability of the vessels. 

Recapitulation. From what has been said the student will observe 
that oedema may be local or general ; that local oedema may be uni- 
lateral or bilateral ; that oedema may be further subdivided, in accord- 
ance with the cause, into inflammatory dropsy, oedema or dropsy of 
passive congestion, hydremic dropsy, and vasomotor dropsy. The 
forms of passive dropsies just indicated may be subdivided into cardiac 
dropsy, hepatic dropsy, and renal dropsy, according to anatomical 
causes. 

AVhile the account of oedema just given refers more particularly to 
the subcutaneous accumulation of serum, the same pathology and 
etiology apply to accumulations in the large lymph-cavities, and hence, 
in addition to general oedema, we may have ascites, hydropericardium, 
hydrothorax, hydrocele, and effusion in the joints. The methods of 



1 54 GENERAL DIA GNOSIS. 

recognition of dropsy of the larger cavities will be deferred until dis- 
eases associated with these particular regions are discussed. It must 
be remembered that oedema or accumulations of serum in cavities may 
be of local or general origin. 

It must not be forgotten that two or more causes may combine to 
produce a dropsy, or that a dropsy of one cause may for a time be 
dependent upon a second and even a more pronounced factor later on 
in the development of the disease. Thus (a) the dropsy of hydremia 
may be aggravated by that of (6) weak heart which arises from 
anaemia, to which may be added later the dropsy of vasomotor paresis. 
The dropsy in Bright' s disease is due to (a) capillary changes pro- 
duced by a poison circulating in the blood, and (6), later, to the con- 
dition of the heart if, as is frequently the case, it undergoes dilatation. 

Myxoedema. 

Enlargement of the surface of the body, local or general, is also seen 
in myxoedema, a condition which simulates dropsy, as already stated. 
In myxoedema the swelling is general. The face is involved. The 

Fio. 20. 




A typical case of myxoedema. (Starr.) 



arms are more markedly swollen, however, than the fingers ; the legs 
more than the feet. Usually the swelling of the legs and arms is 
irregular. In some cases supraclavicular paddings are marked. These 



THE DATA OBTAINED BY OBSERVATION. 155 

paddings must not be confounded with the pseudo-lipomata, described by 
Verneuil, occurring in these situations. The swelling is due to the 
infiltration of mucin into the connective tissue, and arises from some 
affection of the thyroid gland. The gland is absent, functionally or 
actually. The hard, indurating, non-pitting swelling is associated 
with striking change in the appearance of the face, particularly the 
nose and forehead. The nose becomes thickened, the forehead more 
prominent and overhanging. The outline of the face is rounded, so 
that the term " full-moon " is applied to it. The skin is thickened, 
dry, and rough, somewhat translucent in appearance, pale or yellow in 
color, and of a doughy consistence, but with a moderate degree of elas- 
ticity. The perspiration is diminished. The hands change in shape, 
they become square or spade-shaped, and the fingers clubbed. The 
appendages of the skin change. The nails become brittle and dis- 
torted, the hair dry, harsh, and brittle, and it may fall out. With 
these remarkable changes in the exterior marked nervous and mental 
symptoms arise. Speech is thick and hesitating, the memory feeble. 
The intellect is dull and irresponsive, the temper irritable. Sensibility 
is impaired, particularly the loss of sensation to pain. Patients have 
been burned without their knowledge. This happened in one of the 
writer's cases. Abnormal sensations of heat and chilliness are com- 
plained of, as well as other paresthesias. The patient is anaemic, the 
temperature is subnormal, the heart's action weak, the respiration slug- 
gish. Breathlessness on slight exertion is pronounced, and exertion 
itself is very difficult, while there is a greater sense of fatigue than the 
exertion and the condition of the organs would warrant. The mus- 
cularity is enfeebled. There are impairment of appetite, indigestion, 
and flatulency. The urine may become albuminous, but for a long 
time is not characteristic save in amount and specific gravity. The 
former is increased, the latter lowered. 

As the case advances mental and physical failure become more pro- 
nounced, the patient is subject to hallucination, and is extremely irrita- 
ble. Stupor sets in ; death may take place in coma or from uraemia. 
It is a disease of mature life, and occurs most frequently in women. 

The following varieties are seen : (1) Spontaneous myxoedema of 
the adult ; (2) infantile myxoedema ; (3) operative myxoedema ; and 
(4) endemic myxoedema or cretinism. In infantile myxoedema the 
functions of the thyroid body are suppressed during the period of the 
development of the individual. Typical cases justify the name of 
myxoedematous idiocy. 

Subcutaneous Emphysema. 

Enlargement or swelling of the surface, either local or general, 
may occur on account of air underneath the skin. The skin is pale 
and quite distended, and hence depressions are filled up, as the axil- 
lary, clavicular, and intercostal spaces. The primary seat of the swell- 
ing is in close proximity to the air-passages, and occurs because of 
communication between them and the subcutaneous connective tissue. 
It may occur in ulcerations of the upper passages, as the larynx or 



156 



GENERAL DIAGNOSIS. 



Fig. 21. 



trachea ; in ulcerations of the oesophagus into the mediastinum ; in the 
ulceration and rupture of phthisical cavities into the chest-wall ; and 
in rupture of the lungs from hard coughing, sharp crying, severe 
exertions, such as blowing of wind instruments. The air may escape 
under the pleura to the mediastinum and thence to the neck, or, when 
the pleura is adherent, air will pass from the lung into the connective 
tissue. The swelling gradually spreads over the entire body from the 
seat of rupture or in close proximity to it. In a case of laryngeal 
phthisis under the writer's care it encircled the neck and spread uni- 
formly over the anterior and posterior portion of the thorax. Thence 
it extended downward until it met a corresponding infiltration of the 
lymph-spaces in the thighs, due to serum. The distinction between 

oedematous swelling and subcutaneous 
emphysema could thus be made : the 
latter offered no resistance, did not 
pit on pressure, crackled under the 
finger, and was quite tender on press- 
ure. Spontaneous pain was not pres- 
ent ; but any position was painful in 
which the weight of the body pressed 
upon the part affected. 

Connective-tissue Dystrophies. 

Enlargements of the surface are 
seen in the so-called dystrophies. 
The dystrophy is usually due to a 
localized anomalous overgrowth of 
connective tissue, probably of trophic 
origin. It can easily be distinguished 
from oedema by the absence of the 
signs of oedema, or from local inflam- 
matory swelling by the absence of 
pain, heat, and redness. The swell- 
ing occurs on the arms and legs, 
usually on the outer aspects, and may 
occur in various portions of the trunk. 
In one of t^ojirriter's cases the swell- 
ing were periodical ; or, rather, the 
persistent swirlings increased in size 
at irregular intervals. 

Dercum and Henry have described 
cases of dystrophy in which the en- 
largements had been attributed to 
accumulations of fat. The patients 
presented marked subjective nervous 
phenomena, paresthesias of all kinds, 
sinking and depression. There were 




Note accumulations on back and on ex- 
tremities. See knees and elbows ; wrists and 
ankles unusually small, Patient aged 56. 
Second attack of insanity. (Original.) 

with flushings and sensations of 



areas of anesthesia, pain, and tenderness in the nerve-trunks. Pain 
preceded the advent of the swellings. 



THE DATA OBTAINED BY OBSERVATION. 157 

Herpes zoster occurred in Dercum's case, and other symptoms of 
neuritis were marked. The irregularity in the distribution of the 
swellings, their character and mode of development, the occurrence of 
neuritis, and the absence of perspiration, distinguished dystrophy from 
lipomatosis or excess of fat. The patients were of a neurotic type, and 
mental impairment usually resulted in the course of the disease. The 
general nutrition failed, particularly as gastro-intestinal disorders 
ensued. 

Scleroderma. 

Scleroderma is a hyperplasia of the subcutaneous connective tissue 
with swelling and induration. It is brawny. As the tissues are almost 
immovable, the term "hide-bound " is applied to this condition There 
are marked stiffness and also pain. 

In localized scleroderma, or morphoea, the skin has a waxy or dead- 
white appearance, is brawny and inelastic. There may be preliminary 
hyperemia of the skin. Subsequently pigmentation of the hypersemic 
area takes place, causing changes in color, or the pigment may atrophy, 
causing leucoderma. The secretion of sweat is diminished or entirely 
abolished. In the diffused form the affection begins in the extremities 
or face, and is accompanied by a sense of stiffness or tension ; the skin 
is usually hard and firm, and gradually a diffuse, brawny induration 
develops. The skin cannot be picked up in folds. It may appear 
normal, but is generally very smooth, glossy, and dryer than usual, 
rarely pigmented. Scleroderma may be confined to a limb or may 
become universal. The appearance of the face is characteristic. It is 
expressionless, and the lips cannot be moved, while mastication is im- 
possible ; the eyes and the nose are deformed ; the hands become fixed 
and the fingers immobile and contracted, on account of induration 
about the joints, the deformity being called sclerodactyle. It is thought 
to be due to a trophoneurosis, or to fibrosis of the arteries of the skin, 
with connective-tissue overgrowth in the adjacent areas. 

Brawny Induration. 

(Edema must not be confounded with the brawny induration of the 
calves of the legs in scurvy, probably from deep-seated hemorrhage. 
It must be remembered, however, that oedema of the ankles is very 
common in this affection. Brawny induration may also be found in 
syphilis. In a patient recently under the writer's care, in the Presby- 
terian Hospital, a brawny induration of the thigh, with painless swell- 
ing and stiffness of the leg, appeared to be due to syphilis. It disap- 
peared rapidly under treatment with potassium iodide. 

Localized Subcutaneous Nodules. 

Sarcomata. The subcutaneous nodules seen in these affections are 
rarely, if ever, confounded with oedema or other swellings. In sar- 
coma the subcutaneous tumor becomes attached to the skin and may 
change its color. It is usually secondary to sarcoma in some other 



158 GENERAL DIAGNOSIS. 

organ of the body. When primary, or secondary to organs in which 
there is normal pigmentation, as the eye, they become blue or bluish- 
black. On palpation the surface is found to be rough and uneven if 
the tumors are numerous. 

Primary melanotic sarcomata of the skin can always be distinguished 
by their color. In both forms of sarcomata the general symptoms of 
this affection daily become more and more pronounced, and subcuta- 
neous hemorrhages are commonly associated with the local phenomena. 

The first external evidence of lymphosarcoma may be subcutaneous 
nodules in unusual situations. Thus, in a case under my observation, 
a lymphoid nodule was first observed in the third interspace on the 
right side. Subsequently the glandular involvement followed. 

Carcinomata. Subcutaneous lymphatic glands may be the seat of 
secondary carcinoma, and from their location may indicate the primary 
source of the disease. The glands above the left clavicle are some- 
times secondarily affected in cancer of the stomach. In similar dis- 
eases of abdominal organs glands in the abdominal wall are enlarged. 
The subcutaneous nodules should be removed and examined microscop- 
icall y. The structures of the umbilicus (skin and subcutaneous tissues) 
enlarge, become nodulated, and sometimes the seat of fungoid ulcera- 
tion in abdominal carcinoma, particularly of the stomach. It must 
not be forgotten that primary sarcoma or carcinoma of the skin, lim- 
ited to one area, and simulating an intra-abdominal growth, may occur, 
as in a case under my care in the Philadelphia Hospital, operated on 
by Horwitz. 

Oysticercus Cellulosse. The nature of the subcutaneous nodules 
of cysticercus are recognized by microscopic examination. They are 
usually associated with the larvae in other tissues, hence the patient 
complains of great soreness and stiffness, and may become helpless. 

Rheumatic Nodules. Subcutaneous nodules are seen in rheumatic 
patients in the course of the disease, or after the attacks. They are 
common in the young. They are particularly frequent in cases of 
rheumatic endocarditis. They may occur independently of the articu- 
lar symptoms. They may occur in large numbers, and vary in size 
from a small shot to a large pea. They are of fibrous structure. 
They are attached to the tendons and fasciae, particularly on the fingers, 
hands, and wrists, but may be found over the elbows, knees, the 
scapulae, and the spines of the vertebrae. 

Syphilitic Nodes. Gummata are observed in the tertiary periods 
of. syphilis. They must not be confounded with the enlarged glands. 
They are attached to the skin, and may from time to time ulcerate. 
They may be seen on the back or buttocks ; less frequently on other 
parts. 

The Lymphatic Glands. 

Information of diagnostic value may be obtained from the condition 
of the lymphatic glands. (See Chapter VII.) Enlargement may be 
general or local. 

Enlargement of the cervical glands, and of the axillary and inguinal 
glands attended by fever, occurs in that obscure infection described by 



THE DATA OBTAINED BY OBSERVATION. 159 

Dawson Williams and others called glandular fever. Similar glandu- 
lar enlargement is quite characteristic of German measles or rotheln. 
(See the Infections.) 

Enlargement of the post-cervical glands, the epitrochlear glands, and 
lymphatic glands in other portions of the body points to syphilis. In 
the two first-mentioned localities the enlargement is of great diagnostic 
importance, as it is less likely to be due to any other causes. Suppu- 
rating glands do not here concern us. 

Inguinal and Axillary Enlargement. With or without suppuration, 
enlargement always points to an irritation or lymphatic invasion in 
the area drained by the affected lymphatic gland. When in the groins 
the feet are affected, and when in the axillae the hands. Great enlarge- 
ment in either situation causes oedema of the corresponding extremity 
if the veins are pressed upon. The axillary glands are early affected 
and enlarged in mammary cancer. The breast should always be 
examined in oedema of the arm. 

The Supraclavicular Glands. These glands are often enlarged 
and indurated, and may cause pressure-symptoms. The only local 
enlargement that is of special diagnostic significance is that which is 
seen above the clavicle on the left side. They often point to carci- 
noma of the stomach, as Troisier announced. 1 Indeed, there are cases 
of this disease in which only the general symptoms of carcinoma are 
present. Local symptoms are wanting and the locality of the cancer 
cannot be made out by the symptoms. The enlarged glands above the 
clavicle are a fair indication that the stomach is the seat of the disease. 
The enlargement is probably due to transmission of the infection 
along the thoracic duct and its lodgement in the associated glands. 

The Cervical and Submaxillary Glands. Enlargement of the 
submaxillary and cervical glands points to affections of the mouth 
and throat or of the jaw and teeth. It is caused particularly by infec- 
tious disorders in these localities. They are often the seat of nodular 
enlargement in actinomycosis. (See " collar " in adenitis of leukaemia.) 

Scars at the site of former glands point to tuberculous destruction 
or former bubo, and are suggestive. 

The glands are enlarged in simple adenitis, tuberculosis, Hodgkin's 
disease, leucocythcemia, sarcoma, and cancer. The moderate enlarge- 
ment of syphilis and the local enlargement from irritation in the area 
of lymph-drainage have been mentioned. Adenitis is usually local. 
The gland is tender and the connective tissue around it is affected. 
There are local heat and pain. At first the gland is hard, later it 
softens in the centre, and finally it exhibits fluctuation. In tuberculosis 
more than one gland is affected. Usually the glandular involvement 
is bilateral (as in the neck). At first the glands are isolated. Later 
they become matted. The local symptoms are not marked and the 
process is very indolent. Thick, cheesy pus is discharged which may 
contain tubercle bacilli. It causes tuberculosis when inoculated in 
lower animals — a method of diagnosis necessary to be resorted to fre- 
quently. The tuberculin test must be used. Fever and " decline " 

1 Bulletin et Memoires de la Societe Medicale des Hopitaux, January 13, 1888. 



160 



GENERAL DIAGNOSIS. 



occur later, but often not until other structures, as the lungs, are in- 
fected. (See Leucocythaemia.) 

Lympho Sarcoma is an infection of the glandular structures of ob- 
scure origin. A local group of glands may be involved or the glands 
throughout the body may be the seat of the overgrowth. When the 
infection is general the deep-seated glands, as the mediastinal and 
retroperitoneal, may be the first involved. Anaemia, fever, and signs 
of intrathoracic and abdominal pressure may be present without decisive 
indications of the nature of the disease. In a short time, however, a 
superficial gland may enlarge, and from thence rapidly other glands be 
involved. The occurrence of an enlarged gland in any part of the 
body may be suggestive of the nature of a deep-seated process. Posi- 
tive diagnosis can be established, and the method should be resorted 
to by removal of the gland and its examination microscopically. A 
case of this character seen with Hare showed the first evidence of 
glandular infection in the enlargement of a small gland over the third 
interspace on the right side of the chest in front. 



Hodgkin's Disease. 

Hodgkin's disease (pseudoleukemia, lymphadenoma, or lymphatic 
anaemia) is characterized by enlargement of the lymphatic glands and 

other adenoid tissue ; by pro- 
gressive oligocythemia with- 
out, in most cases, much in- 
crease of leucocytes ; and by 
the development of lymphatic 
tumors in unusual situations. 

The disease is most frequent 
in the first half of life, three- 
fourths of the cases bemg in 
males. 

The first symptom noted is 
enlargement of the glands of 
the neck ; but sometimes the 
inguinal, less frequently the 
axillary glands, are first en- 
larged ; rarely the tonsils are 
the first to be affected. The 
enlargement is painless and 
progressive, appearing first on 
one side of the neck and ex- 
tending under the jaw to the 
opposite side. The tumors at 
first are distinct and movable 
under the skin. The swollen 
glands may remain in this condition indefinitely for months or years ; 
but eventually they begin to enlarge very rapidly, lose their separate 
identity, and coalesce into large masses. Other glands in remote parts, 
as the axilla and groin, retroperitoneum, and arm, are affected. They 




Ir 






Hodgkin's disease. Glands in right axilla and neck 
much enlarged. 



THE DATA OB TA IN ED B Y OB SEE VA TION. 161 

may be soft and fluctuating, or very dense and hard, but heat, tender- 
ness, suppuration, and other evidences of inflammation are absent. 

The spleen becomes very much enlarged, but rarely attains the 
dimensions common in leucocythaemia. 

Other adenoid tissue in the intestine, tonsil, and posterior nares, 
and even the thymus, may enlarge and give rise to pressure symptoms. 

Fever is a very constant symptom, but the type is not constant. The 
onset of the disease may be marked by fever and constitutional symp- 
toms, and the glandular enlargement appears later. On the other 
hand, in three cases reported by J. Dreschfeld, 1 all the patients enjoyed 
good health and were able to follow their work until a few weeks 
before death. In all symptoms appeared suddenly, and consisted of 
pain, weakness, pallor, loss of appetite, and pyrexia. 

Coincident with the rapid and extensive enlargement of the glands, 
anaemia becomes pronounced and is accompanied by the usual symp- 
toms. Cough is often associated with anaemic dyspnoea, and in women 
menstruation may cease. 

Along with the general symptoms there are numerous local ones, 
due to the pressure or impairment of function — cerebral anaemia from 
pressure on the carotids ; cerebral congestion from pressure on the 
veins of the neck ; disturbance of the heart from pressure on the 
pneumogastric ; deafness ; difficulty in deglutition and mastication ; 
and pleural, peritoneal, and pericardial effusions. 

The most frequent complications are nephritis, fatty degeneration of 
the heart, pleurisy, and, less frequently, pneumonia and pericarditis. 

The duration of the disease is from six to eighteen months. Two- 
thirds of fifty fatal cases referred to by Gowers 2 ended in less than two 
years. It is difficult to determine accurately the beginning of the 
disease ; sometimes a long period of latency follows the early glandular 
swelling ; sometimes a general anaemia precedes any noticeable swelling 
of the glands ; and sometimes the disease runs an acute course, ending 
fatally in two or three months. 

Death results most frequently from exhaustion ; but pressure upon 
the trachea producing asphyxia is not uncommon, and death has 
occurred from starvation, the result of occlusion by pressure of the 
oesophagus. The complications already mentioned are the immediate 
causes of death in other cases. 

The diagnosis is not difficult with blood examination. By this means 
leucocythaemia is excluded. It may be distinguished from tuberculosis 
in the early stages when local by the site of the enlargement. In the 

I former the submaxillary glands are involved ; in the latter the glands 
in the anterior and posterior cervical triangles. The tuberculin test is 
required, as insisted upon by Otis, to establish tuberculous adenitis. 
Lymphangitis or Angioleucitis. The streaked redness over the 
surface of the skin, with tenderness along the course of the lymphatics 
and oedema, is characteristic of inflammation of the lymphatic vessels, 
and need not be further mentioned. The glandular and dermal changes 



1 British Medical Journal, April 30, 1892. 

2 Reynolds' System of Medicine, Philadelphia, 1880, vol. iii. 549. 

11 



162 GENERAL DIAGNOSIS. 

of elephantiasis, with chyluria, with or without lymph scrotum, are 
unmistakable ; the disease is due to Xhefilaria sanguinis hominis. 

Lymphatism. Poor physical development has recently been ob- 
served with lymphatic overgrowth, or the constitutio lymphatieo. In 
this state sudden death is liable to occur. It is believed that one of 
the causes of death from anaesthesia and from antitoxin of diphtheria is 
a condition known as status lymphaticus. Hyperplasia of the lym- 
phatic glands, the spleen, the thymus, and the bone marrow are rarely 
found in patients with rhachitis, and in hypoplasia of the heart and 
aorta. The internal lymphatic glands and the lymphatic structures of 
the alimentary tract are more frequently involved than the more 
external glands. With this overgrowth of lymph-tissue the spleen 
and the thymus gland are enlarged, and red marrow replaces the yellow 
marrow in young adults. The hypoplasia of the vascular system is 
not easily recognized. The left ventricle may be dilated and the 
peripheral arteries diminished in size. 



CHAPTER XII. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 

The muscles — idiopathic muscular atrophy — pseudohypertrophy — Thomsen's disease — 
paramyoclonus multiplex. Myositis — myalgia — muscular rheumatism. 

THE MUSCLES. 

The Nutrition. The nutrition of the muscles is observed by the 
hand of the examiner while the muscles are made to relax and contract 
alternately. We compare corresponding muscles of the two sides. 
Measurement of the limbs at corresponding situations makes the obser- 
vation more accurate. The muscles may atrophy or hypertrophy. 
Either condition may be local, unilateral, bilateral, or general. 

Myoidema is a local contraction of the muscle which occurs upon 
striking it with a pleximeter or the finger, as in percussion. It is more 
particularly seen in thin subjects, usually tuberculous, and elicited by 
tapping the pectoral muscles. The fasciculi raise in little humps, which 
persist for a short time and gradually subside. At one time they were 
thought to be diagnostic of tuberculosis. They are of no special 
significance. 

Atrophy. 

There are several varieties of atrophy : 1. The atrophy of disuse. 
2. Myopathic atrophy. 3. Myelopathic atrophy, or the atrophy of 
degeneration. It follows lesions of the motor path, of the cortex, 
medulla, or spmal cord ; and neuritis. (See Nervous Diseases.) 

The Atrophy of Disuse. It is also known as the atrophy of inac- 
tivity. The muscles are slightly lessened in volume. The atrophy 
takes place very slowly ; it supervenes in cases of paralysis and in 
the joint-diseases which cause immobility. It occurs also in joint- 
disease from reflex influences. The electrical reactions of the muscles 
are qualitative and unchanged. By this reaction atrophy from disuse 
and atrophy from disease of the muscles can be distinguished from myelo- 
pathic atrophy, due to disease of the nerves (neuritis), or to degeneration 
of motor nerves and ganglia. 

Myopathic Atrophy. Muscular Dystrophy. In this form of 
atrophy the muscle is diseased. It diminishes in volume and finally 
becomes completely shrunken. Complete paralysis rarely ensues, but 
the reaction of degeneration cannot be determined. 

Idiopathic Muscular Atrophy. Dystrophia muscularis pro- 
gressiva (Erb). In this affection muscular wasting takes place with or 
without initial hypertrophy. Three forms are seen : 

1. Atrophy with Pseudohypertrophy. It usually begins in 
childhood, and is often of congenital origin, being transmitted through 



164 GENERAL DIAGNOSIS. 

the mother. It is first noticed just as the child is learning to walk. 
The extensors of the leg, the glutei, the lumbar muscles, the deltoids, 
and the triceps and infraspinati muscles are involved, but the first 
change takes place in the muscles of the calves. The muscles of the 
face, neck, and forearm are not usually affected in this form of the 
disease ; the muscles of the hand are not involved. While hypertrophy 
progresses in certain muscles others waste. The calves may hypertro- 
phy, for instance, while the extensors of the leg waste away and become 
weak. Attitude and gait are characteristic. (See page 7.3.) The patient 
stands erect, with the legs apart, the shoulders thrown back, the spine 
curved, and the abdomen prominent. The waddling gait is character- 
istic, and the method of getting up from the floor is pathognomonic. 
The course of the disease is slow, wasting follows the hypertrophy, but 
the weakness is greatest in the muscles first atrophied. Contractures 
and distortions of the spine and of the bones of the leg take place. 

2. Primary Atrophy. This is likewise congenital or manifests 
itself in early life. It is divided into different types, according to the 
groups of muscles that are affected. The same process occurs as in 
the former, except that pseudohypertrophy is not primary. There 
may be several forms in different members of the same family. Of 
these we have the juvenile form of Erb. The upper arm and shoulder 
and the thigh muscles are first involved. Later the muscles of the 
gluteal region and calf may become enlarged and hard. The back 
muscles are gradually affected, inducing the attitude previously men- 
tioned. The reaction of degeneration is not present. There is also an 
infantile type, first described by Duchenne, or the fascio-scapulo-humeral 
type. Erb's form begins about puberty. The other forms usually 
begin in childhood, but may be delayed. The face is involved ; it is 
expressionless, and in laughing the muscles move slowly ; the child 
cannot whistle, as the lips are thick and everted. The eyes remain 
partly open. The muscles of the group waste ; later the thighs become 
involved. Erb has given a useful test to determine the strength of the 
shoulder and girdle muscles. When the child is lifted by the armpits, 
if the scapulohumeral groups are weak, the shoulders are forced up to 
the child's ears without resistance. 

3. Peroneal Atrophy. A peroneal type of muscular atrophy has 
been described by Charcot. The extensors of the great toe and after- 
ward the common extensors and peronei muscles are affected ; club- 
foot results. The muscles of the thigh may become involved later. 
When the disease occurs in childhood it gradually spreads to the upper 
extremities and affects the muscles of the hand, differing in this respect 
from other forms of muscular atrophy. The thenar, hypothenar, and 
interossei muscles are symmetrically involved, producing the claw-hand. 
Unlike the other forms of atrophy embraced under this heading, the 
peroneal type is attended by disturbances of sensation, and by pain, fibril- 
lary contractions, and vasomotor changes. The reactions of degeneration 
may be present. It is thought by competent observers to be simply a 
form of neuritis ; and it is also called progressive neural muscular atrophy. 

Diagnostic Features of Myopathic Atrophies. The disease 
is characterized by gradual progression of the wasting and weakness in 



THE DATA OBTAINED BY OBSERVATION. 



165 



various groups of muscles not specially related. We never see wasting 
of the intrinsic muscles of the hands, as in the spinal forms of muscular 
atrophy, or of the tongue, pharynx, larynx, and eye. Electrical irri- 
tability is lessened and reaction of degeneration is not present. Fibril- 
lary twitching is not seen. Sensation is not affected. The reflexes are 
diminished and later may be lost. The sphincters are not involved ; 
deformities about the joints or in the spinal column may occur. 

The diagnosis of idiopathic muscular atrophy is not difficult if the 
above-mentioned facts are borne in mind. The fact that it occurs in 
family groups is an important point in the diagnosis. In cerebral 
atrophy there is primary loss of power. In chronic anterior poliomy- 
elitis (spinal atrophy) wasting begins in the muscles of the hands ; in 
both the simple and spastic form there are reactions of degeneration, 
fibrillary twitching, and increase in the reflexes, and, in the latter, 
spastic contraction of the legs. The myopathies occur early in life, and 
are hereditary. 

In neuritis the paralysis is proportionately greater than the atrophy. 
Sensory symptoms are often present. The cause is distinct. There is 
no family history. 

General Atrophy. In cachexias the muscles as well as the tissues 
undergo atrophy. Even in nervous disease the atrophy of the muscles 
markedly increases when general wasting takes place. 

Raymond's Table of Atrophies. 



Circumscribed atrophies 



Progressive atrophies 



Progressive myopathic . 



Diffuse atrophies 



r Atrophy from compression. 

■< Atrophy in inflammatory conditions (pleurisy, joint-disease, etc.). 
*■ Atrophy from injury or inflammation of individual nerves. 

' Progressive spinal muscular atrophy ; type Aran-Duchenne. 

' Pseudohypertrophic muscular paralysis. 
Type Leyden-Mobius. 
Type Zimmerlin. 
atrophy . . ". . . \ Type Erb. 

Type Landouzy-Dejerine. 
Type Charcot-Marie. 

Infantile form. 

Acute of adults : spinal paralysis, with 
rapid course and curable (Landouzy- 
Dejerine) ; subacute and chronic form ; 
chronic mixed form ( Erb ) ; diffuse 
subacute, general spinal paralysis 
(Duchenne). 



Anterior poliomyelitis - 



I Syringomyelia. 



{,,,.., ... r Lead paralysis. 

Multiple neuritis { Lep rous neuritis, 

(amyotrophic form) \ ^^ ^^ 

Muscular atrophies of cere- , With seC ondary degeneration involving the anterior cornua. 

)ra origin \ wi^o^ secondary degeneration involviug the anterior cornua. 

Muscular atrophy in hysteria ) . .. 

Muscular atrophy from sys- L Amyotrophic scleros.s. 

temic disease of the cord . j ^osso-labio- laryngeal paralysis. 

(Atrophy in myelitis. 
Atrophy in compression of the cord. 
Atrophy in multiple sclerosis. 
Atrophy in tabes dorsalis. 



166 GENERAL DIAGNOSIS. 

Hypertrophy. 

Hypertrophy of individual muscles occurs from overuse, as when an 
extremity or a portion of the trunk is used in excess. General hyper- 
trophy of muscles occurs in Thomsen's disease. True hypertrophy is 
recognized by increased volume, great hardness, and increased vigor of 
the muscle. 

Pseudo-hypertrophy (see under Muscular Atrophy) is associated 
with increased volume of muscle but diminished power. 

Thomsen's Disease {Myotonia congenita). This is an hereditary 
disease and may occur in several generations of a family. Tonic 
cramps take place in the muscles when voluntary movements are 
attempted. The disease begins in childhood, rarely after puberty. 
The muscles become rigid and fixed when put in action. The lack of 
voluntary control of the muscles is shown by the slow contraction and 
relaxation when voluntary efforts are made. The rigidity may wear 
off and the limb can then be used. It is particularly noticeable when 
walking is attempted. As the leg is advanced slowly it may remain 
stiff for a second or two, but after it becomes limber the patient can 
walk for hours. If he stops walking the same difficulty is experi- 
enced when he starts again. Both arms and legs are affected. Patients 
are usually well nourished, however. There are no atrophies. The 
muscles are irritable, so that mechanical stimulus or pressure causes 
tonic contraction. Movement and cold aggravate it. Sensation and 
the reflexes are not affected, and there is no evidence of disease of the 
cerebro-spinal system, save the occurrence of hypochondriasis in some 
cases. The myotonic reaction described by Erb is induced. (See 
electrical diagnosis — Diseases of the Nerves.) 

Paramyoclonus Multiplex. In this affection there is clonic con- 
traction of the muscles. It is usually confined to the extremities and 
occurs in paroxysms. It may have been caused by sudden twitching 
or violent motion. The clonic spasms at first do not interfere with 
the patient's occupation, but gradually they increase. Both legs are 
affected, and the number of contractions varies from 50 to 150 a minute. 
The contractions may be rhythmical. In severe cases the muscles of 
the back and abdomen contract violently. Tremor of the muscles 
may be present in the intervals. (For paralysis, spasm, tremor, contrac- 
tion, etc., see Nervous System.) 

Myositis. Inflammation of the muscles. (See also Trichinosis.) In 
inflammation of the muscles there is pain, swelling, and loss of power. 
In universal myositis the inflammation begins in the lower extremities 
and gradually involves other muscles of the body. They are swollen, 
hard, and painful on pressure. Atrophy supervenes in groups of 
muscles. The muscles may become more or less rigid. Local oedema 
of the skin over the muscles occurs. The progress is gradual, and 
death ensues when the respiratory muscles are involved. 

The three cardinal symptoms that attend the disease as described by 



THE DATA OBTAINED BY OBSERVATION. 167 

Loenfeld are : (1) Swelling of the extremities due to subcutaneous 
oedema and swelling of the muscle, causing functional disturbance ; (2) 
extension to the muscles of respiration and deglutition ; (3) a more or 
less extensive eruption. The latter is erythematous, its distribution is 
usually general but irregular, and may be followed by pigmentation. 
The disease must not be confounded with trichinosis. In the latter 
examination of a small portion of muscle reveals the trichinae. 

Progressive ossification of the muscles is rare. The muscle-tissues 
undergo gradual ossification, either in localized spots or in wide-spread 
areas. Inflammation of the muscle precedes the ossification. As the 
inflammatory swelling subsides the muscles become hard and are grad- 
ually converted into bony tissue. The disease lasts many years. 

Myalgia is an inflammation of the muscles produced by cold or 
trauma. There is pain on movement and spontaneous pain in the 
muscle ; it is tender on pressure. It may be the seat of spasm. 

Muscular Rheumatism. In this variety of rheumatism there is pain 
in the affected muscles, which often comes on suddenly in the night, 
or is first noticed when the patient attempts to rise in the morning. 
The pain when the patient is at rest may be inconsiderable, rarely 
amounting to more than a dull, aching, sore feeling ; on attempting to 
move, to bend, or twist, or straighten himself, however, the patient 
catches himself suddenly on account of the agonizing, tearing, or burning 
pain. When the muscles are relaxed the patient is fairly comfortable. 
Sudden movement is the most painful. The affected muscles are 
tender to the touch and to sharp blows. Muscular rheumatism may be 
acute or chronic. In the latter the symptoms are very much like those 
of chronic articular rheumatism, except that the muscles and not the 
joints are affected. There is the same proneness to recur in unfavor- 
able weather and in cold, damp seasons. 

The disease receives different names according to the muscle affected. 
The most common subvarieties are : lumbago, in which the muscles 
of the small of the back are affected ; pleurodynia, in which the inter- 
costal muscles suffer ; and torticollis, in which the sternomastoid and 
trapezius are painfully contracted. 

In lumbago the patient holds himself rigid and is unwilling to rotate 
the trunk upon the vertebrae. Often the most comfortable position is 
that in which he sits and bends slightly forward over another chair. 
Motion is painful but pressure is not. Fever is absent. There is 
a history of repeated attacks, or of exposure, such as lying upon 
damp ground. Lumbago needs to be distinguished from disease of 
the spinal membranes, from disease of the vertebrae, aneurism, abdomi- 
nal abscess, and diseases of the uterus and ovaries. The diagnosis of 
rheumatism is arrived at by exclusion. 

In pleurodynia there is usually tenderness upon pressure as well as 
upon motion and deep inspiration. The pain is of the same sore, burn- 
ing character, aggravated by coughing and sneezing. The patient 
breathes as little as possible, and often bends over toward the affected 
side to lessen the motion. Pleurodynia is distinguished from pleurisy 



168 GENERAL DIAGNOSIS. 

by the absence of fever, cough, and, above all, of friction-sounds. In 
intercostal neuralgia there are painful points upon pressure, whereas in 
pleurodynia firm pressure is grateful, though tapping is painful. 

In torticollis the head is drawn to one side and fixed in that position. 
The sternomastoid especially is rigid and tender on pinching. In 
spinal affections the head is retracted, and there are antecedent symp- 
toms, as headache and darting pains with fever. 

Fibrous Tissues. Intimately associated with rheumatic affections 
of the muscles is that of the fibrous tissues or fascia. Pain, fixation, 
and tenderness are noted, and if with them other rheumatic manifesta- 
tions are found the diagnosis is established ; especially is the above true 
of trauma. 



CHAPTEE XIII. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 

The bones — general examination. Enlargement — acromegaly — osteitis deformans — pul- 
monary osteo-arthropathy — Diminution — rhachitis osteomalacia. Local examination 
— position and shape — nodes — inflammation — osteomyelitis. 

THE BONES AND JOINTS. 

Method of Examination. When the bones and joints, especially 
the spinal column, are to be examined, the patient should be stripped, 
and after the movements and position in the upright or semi-upright 
position have been noted, he should be made to lie down on a hard, 
smooth surface, and the trunk and joints examined in that position. 
Anterior, posterior, and lateral movements of the spinal column must 
be made to determine its flexibility. In this manner deformities, 
changes in the length of the bones, and abnormal posture can be care- 
fully observed. In addition we must note muscular wasting, the pres- 
ence of local tenderness and swelling, changes in the movements of the 
joints, and loss of other functional activity causing lameness or joint- 
disability. 

To distinguish joint lesions from abnormal flexions or extensions, 
the result of spasm of muscles, anaesthesia must be employed. 

The Bones. 

The bones are fixed landmarks by which the location of organs is 
determined. The student should familiarize himself with the shape of 
the bones and the location of normal tuberosities. 

The bones may be the seat of nutritive changes which involve the 
skeleton in whole or in part, causing enlargement or diminution of the 
osseous system, and hence of the body. Local changes are traumatic 
(periostitis) or infectious, giving rise to nodes or to swellings. 

General Examination. Enlargements. Nutritive changes giving 
rise to enlargement of the bones occur in acromegalia, osteitis defor- 
mans, and pulmonary osteo-arthropathy. 

Acromegalia. 

Marie first described acromegaly, a skeletal change, characterized 
by hypertrophy of the bones of the hands, feet, and face. The fibro- 
cartilages of the ear and larynx are also enlarged. The enlargement 
of the inferior maxillary and frontal bones causes the face to assume a 
peculiar, elongated, elliptical outline. The nasal bones are enlarged, 



170 



GENERAL DIAGNOSIS. 



Fig. 23. 



and the nose thickened ; the temporal fossae are deepened, on account of 
enlargement of the malar bones. The forehead retreats because of the 
enlargement of the frontal sinuses and projection of the superciliary 
ridges ; the chin is prominent and the lower teeth project beyond the 
plane of the upper ; the lips and eyelids may be thickened ; the tongue 
is enlarged and thickened. The hair is coarse and dry ; the face dry 
and pigmented. 

'"— The hands are peculiar ; they are much broader, the fingers are 
sausage -shaped, and the hand spade-like in shape ; the nails are flat, 

striated, and too small. There is usually 
spinal curvature ; the abdomen is prom- 
inent, and, as before intimated, the 
$& height is increased. The muscles be- 

come weak and may atrophy ; the skin 
C. ' mf is often pigmented ; varicose veins have 

been observed, and the patient complains 
of hemorrhoids. The thyroid gland may 
be atrophied or hypertrophied. It may 
be well to state, in passing, that with 
these appearances nervous phenomena 
are observed and disorder of special 
senses complained of. Hemianopsia, 
limitation of the visual field, and blind- 
ness or deafness arise. 

I Osteitis Deformans. 

Another remarkable change is seen 
in the skeleton, and has been described 
by Sir James Paget ; in this there is 
marked change in the contour of the 
patient and a peculiarity in the mode 
of locomotion. It is known as osteitis 
deformans. The head is advanced and 
lowered, so that the neck is very short, 
and the chin, when the head is at 
ease, is more than an inch below the 
top of the sternum. The chest becomes 
contracted, narrow, flattened laterally, 
deep from before backward, and the 
movements of the ribs and spine are 
lessened ; the arms appear unnaturally long ; the shafts of each tibia 
and femur are bent so that the patient becomes bow-legged. There is 
some stiffness, but no loss of power and not a great deal of pain. The 
skull is increased considerably in thickness. 

These changes in the bones cause a dwarfed appearance of the trunk 
in comparison with the legs and arms, and the posterior lateral curva- 
ture necessitates a characteristic attitude. The skeletal changes are 
noted particularly in the long bones. As a result of the enlargement 
of the cranial bones, the face presents a triangular outline, with the base 




Case of acromegaly. (Osborne. 



THE DA TA OB TA IN ED B Y OB SEE VA TION. 171 

above and the apex below (see Fig. 24, outline 3), thus differing in 
appearance from the outline in acromegaly (Fig. 24, outline 2). 

Fig. 24. 









I 


2 


o 


Outline of face in 


Outline in acro- 


Outline in osteitis 


myxcedema. 


megaly. 


deformans. 



Pulmonary Osteo-arthropathy. 

Marie distinguishes acromegaly from another skeletal change in 
which there is hypertrophy of the bones of the extremities, including 
enlargement of the shafts. In this form of arthropathy the bones of 
the head and face are not affected. The hands and feet are enlarged, 
and the patellae and other bones of the knee-joints increased in size. 

Fig. 25. 




Pulmonary osteo-arthropathy. Female, aged eleven. Tuberculous vertebral caries and pulmonary 
tuberculosis. Enlarged clubbed fingers and thickened ulna and radius. Private patient, 1885. 

Curvature of the spine is present. The appearance of the fingers is 
different from that seen in acromegalia. The ends are enlarged and 
bulbous, and the nails are too large and are curved in a transverse and 



172 



GENERAL DIAGNOSIS. 



longitudinal direction, like the clubbed fingers of phthisis, although the 
chief enlargement of the fingers is not terminal, and there is no cyanosis, 
as in phthisical clubbing. The change seemed to be associated with pul- 
monary affections, and Marie called it osteo-arthropathk pneumonique. 



Diminution. 

cretins ; later 
osteomalacia. 



Small development of the bones is seen in idiots and 
life diminution in size may occur from rhachitis and 

Rhachitis. 



In this affection the size of the body is lessened. For its recognition 
it is important to know how rapidly the osseous deposits in childhood 
have formed. The fontanelles and the epiphyses must be examined. 
If the fontanelles are open beyond their period of closure in health, or 
if the epiphyses are enlarged and lack firmness, the condition points 
either to simple malnutrition or to rhachitis. 

In rhachitis late development of the teeth is observed. If the ribs are 
examined, nodules will be detected at the junction of the bone with 



Fig. 26. 



Fig. 27. 








1 "' ' , '*-''W 




1 lilil 1 

• ♦ 1$ m 1 * 

1 1 1 I 

■"Wi f 




~ ' : M 




[ ^^ yJv v~ <mL 




®^^-*r- 




' .-.^tifc. 


•;. .' 



Rhachitis; attitude in sitting; one hand raised 
to exhibit swelling at the wrist. (Williams.) 



Rhachitis in moderate degree in a boy aged 
fifteen months ; showing backward excurvation 
of the spine. (Williams.) 



the cartilage. These may be seen, as well as felt, if the child is thin. 
They form the so-called rhachitic rosary. The thorax also is changed 
in shape. At the junction of the cartilages and ribs a depression takes 
place which is continuous with a groove which passes out from the 
ensiform cartilage toward the axilla. This transverse curve is known 
as Harrison's groove. It may deepen with inspiration. The sternum 
projects, forming the so-called " pigeon-breast." (See Thorax.) Such 






THE DATA OBTAINED BY OBSERVATION. 173 

deformity must not be confounded with a similar one seen in adenoid 
disease. Changes at the lower end of the radius and ulna, and some- 
times at the end of the humerus, are noticed. The parts are enlarged 
at the junction of the shaft and epiphyses. There may be thickening 
of the clayicles at the sternal ends. In the legs the lower end of the 
tibia becomes enlarged, and at times the upper end, or even the shaft, 
becomes thickened. The child becomes bow-legged, or the tibiae and 
femora may arch forward. Knock-knee sometimes occurs. The 
bones of the yertebral column and of the pelyis are also affected. The 
spine is usually curved posteriorly, but the lateral curyature may also 
be produced with it. The contraction of the pelyis is such as to 
narroAV its outlet — a matter of much importance for the future of 
female children. 

The head of the child with rickets is quite characteristic. It has 
been mentioned that the fontanelles remain open for a long time, and 
areas of ossification are imperfect, so that the bone yields to the press- 
ure of the finger. This occurs particularly at the side, and the term 
eraniotabes is applied to it. The large head is square in shape, not 
globular, when seen from aboye downward. It giyes the face a pecu- 
liar appearance. It is proportionately yery small, especially in the 
lower two-thirds, while the forehead is broad and square. 

Rhachitis is usually developed in childhood, and is most common in 
children with bad hygienic surroundings, who haye lived upon a 
starchy diet and haye taken cow's milk for too long a period of time. 
A child that has been nursed during the mother's pregnancy is liable 
to have the disease. 

In addition to changes in the bones a child presents other evidences 
of defective nutrition. There is marked pallor ; the muscles are flabby ; 
the child is feeble ; and the weakness of the muscles results in an inac- 
tion which resembles paralysis. 

The disease usually progresses slowly, and is eminently chronic. A 
form is seen, however, in which the progress of the symptoms is more 
acute. With some gastro-intestinal disturbances there are mild fever, 
considerable weakness, and great restlessness. Sleep is disturbed, and 
pain is complained of if the child is of an age to make such com- 
plaint. Soreness of the body is observed on handling the child ; and 
of its own accord, on account of the pain and soreness, it avoids all 
customary movements. The child lies on its back and shrinks from 
any attempts to disturb it. The pain is not only caused by handling 
of the muscles, but the bones also are sore and tender. Sometimes the 
most marked manifestations of the more acute forms are the gastro- 
intestinal symptoms. It may often happen that vomiting and diar- 
rhoea have as an underlying basis this rhachitic condition. 

With the above symptoms, and also in chronic cases, perspirations 
about the head are common. There is usually more heat of the head 
than is natural, hence in sleep the child rolls the head. This rolling 
causes the hair on the back of the head to be worn off. This sign is 
most characteristic of rhachitis when observed along with changes in 
the skeleton. 

In the acute and chronic forms enlargement of the liver and spleen is 



174 GENERAL DIAGNOSIS. 

observed. The enlargement is not only actual, but also a false enlarge- 
ment may be seen from distortion of the organs, on account of changes in 
the vertebrae and ribs. The abdomen is prominent, usually on account 
of flatulency, although the enlarged organs contribute to the swelling. 

Nervous 'phenomena are common in the course of rhachitis. Tetany, 
limited to the upper extremities, and laryngismus stridulus are the most 
frequent. Either of these complications may occur before the disease 
is other wise suspected. 

Diagnosis. The possible presence of rhachitis must not be over- 
looked in cases of chronic vomiting in childhood. The acute form of 
the disease must not be confounded with scurvy, as often happens in 
the case of children. It must not be forgotten that scurvy may set in 
hi the course of rhachitis. In scurvy the pain, tenderness, and weak- 
ness are limited to the lower extremities. The immobility of the 
extremities may go on to pseudoparalysis. The tenderness, however, 
is great ; oedema is more pronounced, and local areas of periostitis are 
more common. In scurvy the gums are swollen and may be spongy, 
or may be the seat of ecchymoses. The most decisive diagnostic crite- 
rion is the therapeutic test, scurvy rapidly yielding to a proper regimen. 

Osteomalacia. 

Among the general affections of the skeleton which may cause lessened 
size, osteomalacia must not be forgotten. As the lime salts are dis- 
solved the bones become preternaturally soft, break on the slightest 
provocation, or bend in various directions, depending upon the external 
pressure and the direction of the muscular force. The ribs are drawn 
in by inspiratory force until the cavity of the thorax is lessened to a 
degree incompatible with life. The pelvis is deformed so that labor is 
impossible. (It occurs frequently in pregnancy.) All sorts of fixed 
contortions are assumed. If the patient is able to be up the body 
shortens, the back becomes rounded, the neck flexed, so that the chin is 
brought close to the sternum. On palpation the bones can be indented 
with the finger, and crepitate like egg-shells. 

Osteomalacia is easily distinguished from carcinoma or sarcoma of 
the bones. In the latter spontaneous fracture occurs in various parts 
of the skeleton, but is generally preceded by pain and swelling at the 
seat of fracture. Then, in sarcoma, subcutaneous hemorrhages are 
present. When a single joint is affected in osteosarcoma the same egg- 
shell crackling is observed. 

Local Examination. The Position and Shape of Bones. 
The peculiar position (falling downward) of the scapula in paralysis of 
the serratus magnus is diagnostic of that affection, and indicates disease 
of the posterior thoracic nerve. In examination of the clavicles frac- 
tures must not be mistaken for disease of the bones, such as rickets. 
The examination of the spinal column is of the greatest importance. 
(See Spinal Joints.) A study of the diseases of the spinal column due 
to caries from tuberculosis is not within the province of this work ;: 
no physical examination, however, is complete without an investigation 



THE DATA OBTAINED BY OBSERVATION. 175 

of the movability of the spine and the presence or absence of curvature. 
I refer to the curvature due to weakness of groups of spinal muscles. 
Functional disorders of the gastro-intestinal tract and of the uterus 
are undoubtedly intensified by the presence of curvature, which leads 
to deformity of the body, and hence to the assuming of abnormal posi- 
tions when sitting or walking. The recognition of lateral or anterior 
curvature leads to the adoption of lines of treatment which otherwise 
would not be followed, but without which weak muscles, improper 
aeration of the blood, and sluggish circulation would persist. Pain in 
the distribution of nerves, or at their termination, is often due to spinal 
caries pressing on them as they pass through the foramina. The most 
noticeable is the pain about the umbilicus in children due to Pott's 
disease. 

The bones and cartilages connected with the thorax will be consid- 
ered under Diseases of the Lungs. 

Inflammation. The discovery of a slight change may lead to the 
recognition of a grave general process. Simple local inflammation or 
periostitis may be due to syphilis, and is recognized by local pain, swell- 
ing, and slight oedema. It may be diffuse. It is seen most frequently 
on the tibia, sternum, and clavicle. It not infrequently follows typhoid 
fever. 

Nodules or nodes are usually due to syphilis. They form on vari- 
ous portions of the skeleton, but are most frequently seen on the skull, 
especially on the forehead ; they are also found on the shafts of the 
long bones, preferably the tibia, ulna, and clavicles. They are usually 
multiple or bilateral. They are painful and tender on pressure, and 
may be the seat of heat and redness. They are not so hard and dense 
as exostoses. The latter are situated on the outer aspects of the bone 
and in relation with the strongest tendons or muscles. 

As an illustration of the importance of recognizing nodes the writer 
recalls a case of persistent headache, the true nature of which was only 
ascertained by finding a small node on the skull. The headache had 
been of long (five years) duration, and treatment for it had been 
sought in many countries. 

Tenderness of the sternum upon pressure is often of diagnostic signifi- 
cance and is usually indicative of syphilis. The pain and tenderness just 
noted, however, must not be confounded with local tenderness due to 
necrosis, which often arises in convalescence from fevers, notably those 
of an infectious nature. 

Osteomyelitis. The occurrence of high fever, with or without 
chills, but usually with pysemic symptoms, without recognized cause, 
should lead to an examination of the bones. A spot of tenderness 
followed by local redness and swelling — on the tibia, for instance — 
would indicate the seat of suppuration in osteomyelitis. 

The Joints. 

The Data Obtained by Inquiry. Careful observation of the bones 
enables us largely to discern the nature of the diseased process, as has 
just been indicated. It is true osteomyelitis is less likely of recognition 



176 GENERAL DIAGNOSIS. 

than any other process, but when the patient has been exposed to an 
infection, and fever is present, this condition must always be sought 
for in the absence of any other infectious area. 

Such is not true, however, of joint-disease. By observation we deter- 
mine the joint affected and in part the nature of the morbid process. 
Other data are needed. Hence we collect the usual data obtained by 
inquiry. The social history is not productive of valuable data. Acute 
rheumatism is more common in early life, rheumatoid arthritis in the 
middle periods, and cnronic rheumatism in late life. Females are 
more commonly attacked than males in rheumatoid arthritis, and this 
affection is more common in the poorer classes. Males and the well- 
to-do are the victims of gout. 

In the family history one learns of the transmission of gout from 
generation to generation and of the occurrence of rheumatism or of 
its various allied processes in members of the same or previous genera- 
tions. Previous diseases elicited are those of an infectious nature or an 
intoxication, as of lead. Such diseases must be sought for if the true 
nature of an arthritis is to be discovered. The history of the present 
disease is often that of recent infection or intoxication. 

The subjective symptoms of joint-affections are worthy of note. Pain 
is the most prominent. This may be spontaneous, or may arise upon 
pressure, or follow attempts at movement. Spontaneous pain with ten- 
derness is more pronounced in rheumatic and gouty inflammations of 
the joints. The pain is usually worse at night. This is particularly 
the case in tuberculous joints, and is due to removal of the apprehen- 
sive spasm of the muscles whereby the joints had been protected. 

Pain in the joints must not be confounded with that of local or mul- 
tiple neuritis. I have seen the pains of neuritis attributed to rheuma- 
tism of the phalanges, tarsus, and ankle until paralysis of the exten- 
sors took place. I have seen the pain of neuritis of the circumflex 
mistaken for shoulder-joint disease. Multiple neuritis is attended by 
pains that may be located in the joints by the patient ; but neither in 
local nor in general neuritis are the joints ever swollen, tender, or 
painful on passive movement. 

Inspection. The size, shape, and color, the degree of movability and 
the position of the joints are observed. 

The Size and Shape. The joints may be enlarged. The enlarge- 
ment may be due to infiltration of the tissues about the joints, to effu- 
sion within the joints, serous or purulent, or to inflammation of the 
ends of the bones. 

1. When the enlargement is due to infiltration about the joint the 
tissues are previously thickened, as shown by palpation, and the out- 
line of the joint is changed. The normal contour is lost entirely, and, 
instead, there is a globular swelling beginning above and extending 
below the joint, 2. When the enlargement is due to effusion it may 
be detected by palpation, as this secures fluctuation. This is particu- 
larly so in the large joints. If the joint involved is the knee the 
patella will float. The effusion changes the normal contour, but, 
in the earlier stages, may cause local swellings where the synovial 
sacs are near the surface ; hence, at the articulation of the tibia and 



THE DATA OB TA IN ED B Y OB SEE VA TION. 1 7 7 

fibula with the tarsus, on the inner and outer side, a boggy swelling is 
observed. At the knee the swelling is on each side above and below 
the patella. When the effusion is great the joint becomes immobile, 
and may be flexed from distention of the sac. 3. When enlargement 
of the joints is due to hypertrophy of the bones the latter are thick- 
ened and very hard. There may or may not be, and usually is not, 
fixation, and movement is but moderately interfered with. 

Changes in the outline of the joint are also seen in rheumatoid arth- 
ritis. The loss of the cartilaginous substance of the joint, with the 
secondary osteophytic changes, causes deformity, so that in the case of 
the small joints of the finger subluxation is seen ; similar subluxations 
are seen in larger joints. The ends of the phalangeal bones are thickened. 

The Color Change in the color is usually noticed in inflamma- 
tions. The surface is either bright red or dusky. 

The Position. The position assumed is of diagnostic importance. 
Flexion of the limb of the affected joint occurs in over-distention. It 
must be remembered that the hip-joint is flexed in appendicitis and in 
psoas abscess or other affections in proximity to the psoas muscles. 
In rheumatoid arthritis there is subluxation. Immobility is observed. 
(See Palpation.) 

Palpation. By palpation we determine the degree of movability of 
the joints, the presence of fluctuation and of crepitation. 

1. The movability of the joint is learned. Movement is inhibited in 
inflammation on account of the pain. A reflex muscular spasm takes 
place if osteitis and cartilage-destruction are present. The spasm pre- 
vents movement. In effusion there is less movability or even none at 
all. In rheumatoid arthritis movement is prevented by the osteophytic 
growths which surround the joint. 

2. Fluctuation is revealed by palpation, pointing to liquid effusion 
within the joint. (Edema of the surrounding tissues occurs in puru- 
lent effusions. 

3. A crepitus or grating sensation is observed in rheumatoid arth- 
ritis and other destructive diseases. 

The Morbid Process. The processes which give rise to change in 
the joints are inflammatory and degenerative, and, curiously, neurotic 
or neuropathic. When a single joint is the seat of disease the process 
may be local, as in traumatic synovitis. But tuberculosis and other 
infections, gout and rheumatism or rheumatoid arthritis, may be local- 
ized to one joint — the latter rarely, however. Multiple joint-disease, 
polyarticular, is infectious or systemic (intoxication) usually. 

Much information, therefore, is learned by noting if the process is 
limited to one joint, monarticular ; or to many joints, polyarticular ; if 
to large joints or to small joints ; if it is fixed, as in synovitis, or fugi- 
tive, as in rheumatic fever. Monarticular inflammation of small joints 
points to gout ; of large joints, to gonorrheal rheumatism or pyremia. 
Polyarticular inflammation of small joints, to rheumatoid arthritis ; of 
large joints, to rheumatism. Lesions may be unilateral or bilateral, 
symmetrical or asymmetrical. Bilateral joint lesions are characteristic 
of rheumatoid arthritis. Asymmetrical and fugacious lesions are seen 
in rheumatic fever. 

12 



178 GENERAL DIAGNOSIS. 

It must always be remembered that joint-lesions or processes may be 
expressions of general infections, as septicaemia, influenza, cerebro-spinal 
meningitis, scarlet fever, and dysentery ; or blood diseases, like purpura 
or haemophilia or scurvy ; or of nervous diseases, like tabes dorsalis. 

We have to consider synovitis or arthritis single and multiple, trau- 
matic, toxic, or infectious, of which gonorrheal and tuberculous infec- 
tions are the most common monarticular causes. We will then consider 
rheumatism and gout, rheumatoid arthritis, and follow with the neuro- 
pathic joints. 

Synovitis. The inflammation is recognized by pain, heat, redness, 
and swelling. Effusion is present, and its physical signs are readily 
elicited. It is both periarticular and intra-articular. It may be due 
to traumatism, but we are chiefly concerned with inflammations due to 
internal morbid processes. When single joints are affected the most 
common causes are tuberculosis, pyaemia, and gonorrhoeal infection. 
A mild degree of inflammation may be limited to one joint in subacute 
rheumatism. When many joints are affected the cause is an infectious 
one, as rheumatism, septicaemia, pyaemia, epidemic cerebro-spinal men- 
ingitis, scarlet fever, and dysentery, rarely gonorrhoea. 

The Tuberculous Joint. In tubercidosis the joint is swollen and 
the neighboring tissue oedematous. Effusion may be detected. There 
is fever. The hip, the knee, the elbow, the wrist, and the ankle are 
most frequently affected. Cheesy material may be withdrawn by tap- 
ping. Destruction ultimately takes place, with subluxations and sub- 
sequent fixation of the joint. With fever, wasting, and local signs of 
tuberculosis in other portions of the body the true nature of the affec- 
tion is indicated. The tuberculous process may be limited to the 
affected joint, extend to the tendinous sheaths, or secondary tuberculosis 
of internal organs may supervene. 

The Joint of Gonorrhoeal Rheumatism. The knee-joint is usually 
affected. Signs of acute or subacute inflammation are present, with 
oedema and effusion. The patient is a male in whom an acute or 
chronic urethral discharge is found. The pain is worse at night. The 
process is of long duration. Metastasis does not take place. Destruc- 
tion rarely occurs, but anchylosis may. General pyaemic symptoms 
may ensue, and^ gonorrhoeal endocarditis supervene. The micro-organ- 
isms (gonococci) can be found in the blood and in the pus of the 
affected joint. There is entire absence of heart-symptoms from simple 
endocarditis. The general and local signs of rheumatism or of a rheu- 
matic diathesis, and changes in the urine, skin eruptions, cardiac 
lesions, etc., are wanting. In certain cases many joints are affected, 
but the temperature is not so high or the sweats so profuse as in acute 
rheumatism. Tendo-synovitis is not infrequent. 

Rheumatic Fever. 

An acute, general, febrile, non-contagious disease, characterized by 
specific inflammation of the joints and their contiguous structures, hence 
called acute articular rheumatism. It is further characterized by a ten- 
dency of the inflammation to involve the larger joints successively, to 



THE DATA OB TA IN ED B Y OB SEE VA TION. 179 

skip from one joint to another, and to be associated with endocarditis 
or pericarditis. 

The predisposing causes of rheumatic fever are heredity, which is 
operative in 25 or 30 per cent, of the cases ; age — 81 per cent, of first 
attacks occur between the eleventh and thirtieth years (Pye-Smith) ; 
sex — in childhood girls are more frequently affected than boys, but after 
that period sex appears to have no influence. Polyarticular inflamma- 
tions, sometimes rheumatic in nature, are met with during convales- 
cence from scarlatina and dysentery. They also occur in association 
with the puerperal state and gonorrhoea, in which they are probably 
pysemic. The nature of the polyarthritis which occurs in connection 
with dengue and haemophilia is obscure. 

Symptoms. The onset of the disease is not characterized by con- 
stant symptoms. Sometimes the fever and joint-inflammations are 
preceded a day or two by debility, wandering pains in the joints or 
muscles, and loss of appetite. In other cases there is a chill or repeated 
attacks of chilliness, followed in a day or two by fever and inflamma- 
tion of the joints. In rare cases the onset may be followed not by in- 
flammation of the joints but by inflammation of the serous membranes, 
particularly those of the heart and its sac. 

The temperature may rise a day or two before there are any joint- 
symptoms, or fever and arthritis may begin almost simultaneously. 
The temperature rises rapidly to 102°, 103°, or 104° F., and one or 
more of the larger joints, generally the knee and ankle, become painful, 
tender, swollen, and hot. 

The Joixt. There may be great pain on motion before there is 
evident swelling or much local tenderness. The pain varies from mere 
discomfort to the most excruciating suffering. It is always aggravated 
by motion or pressure, and is at times so exquisite that the slightest 
touch, the weight of the bedclothing, or the jar of the bed from a heavy 
step in the room makes the patient cry out. It may extend beyond 
the joint to neighboring tendons and nerves. The swelling like- 
wise varies greatly ; sometimes there is only slight pufnness with 
increased distinctness of the cutaneous veins, increased heat in the part, 
but no general redness ; in other cases there is considerable swelling 
about the joint, so that the bony prominences are obliterated, the sur- 
face being tense, red, and very hot to the touch. There is often effu- 
sion into the joint, Swelling is most marked in the wrist and ankle, 
and less so in the shoulders, hips, elbows, and knees. 

Multiplicity of Joints Affected. A characteristic peculiarity of rheu- 
matism is its tendency to involve one joint after another. One or 
several joints may be affected at first ; it is very common for the 
right ankle to be affected, and then in a short time the opposite ankle, 
followed by the left knee and right- knee, and so on with the other 
joints. The inflammation usually lasts in each joint from two to four 
days. The process may subside in one articulation and begin in 
another with startling rapidity. At one visit of the physician the 
patient's right ankle may be swollen, hot, and unbearably painful, and 
on the next day the right ankle may be quite well again and the patient 
be found suffering acute pain in the right knee or left ankle. 



180 



GENERAL DIAGNOSIS. 



The puke in the early stages of rheumatism is moderately accelerated 
(99 to 110) ; it is regular, of good volume, often bounding, and some- 
times hard. The urine is scanty, high-colored, abnormally acid, and 
deposits on cooling a copious precipitate of urates, resembling red sand 
in appearance. The skin does not feel so hot as one would expect from 
the temperature. It is continuously covered with a copious, acid, and 
somewhat pungent perspiration. Nervous symptoms are not marked. 
There may, however, be slight nocturnal delirium. Sleeplessness from 
pain is very common. 

The temperature in rheumatic fever is not usually very high ; it is 
much oftener under than over 103°. In rare cases, however, espe- 
cially when the fever is complicated with pericarditis, pneumonia, or 

Fig. 28. 



103 



102 — i 



101 



100 



9U 



i 



tf 



I 



S 



I 



s 



«5 



May 



Rheumatic fever. Admitted fourth day of disease. 



some disturbance of the heat-regulating apparatus, the temperature 
may attain the extraordinary range of 106°-112° F. Such high tem- 
peratures may occur suddenly or gradually, and are sometimes attended 
with marked brain-symptoms (so-called cerebral rheumatism). 

Endocarditis and pericarditis may occur at any period of rheumatic 
fever ; they may even precede any joint-inflammations. They are most 
common, however, in the first two weeks of the disease. The younger 
the patient and the more severe the attack the greater the liability to 
heart-complications. They occur in about one-fourth of all cases. 
Endocarditis is most common ; often it is the only lesion, but some- 
times it is associated with pericarditis and more rarely with myocar- 
ditis. These complications usually give rise to no symptoms at first. 
Hence the heart should be examined daily. A sense of constriction 
in the prsecordia or pit of the stomach, an anxious expression of the 
face, Avith pallor, a change in the frequency, but especially in the 
rhythm of the pulse, and the occurrence of cough or dyspnoea, should 
attract attention to the heart. The physical signs of the respective 
lesions have been described fully under Diseases of the Heart. 

The setting in of convalescence from rheumatic fever is marked by 
cleaning of the tongue, which also becomes less red, and increase in 
the secretion of urine, which remains of high specific gravity. The 
fever subsides gradually, the joints cease to be red, swollen, and tender, 



THE DATA OBTAINED BY OBSERVATION. 181 

the acid sweats lessen, and the appetite improves. In proportion to 
the duration of the case and its severity the patient is left with debility 
and marked anaemia, both red cells and haemoglobin being diminished. 
In ansemic cases a haemic murmur may be heard over the base of the 
heart. In some cases acute dilatation has been observed, with a tri- 
cuspid murmur. 

Complications and Sequelae. Apart from heart complications which 
have been mentioned, pleuritis, pneumonia, and bronchitis occur in from 
10 to 15 per cent, of the cases. They are frequently bilateral, and are 
very much more common in rheumatic fever with pericarditis or endo- 
carditis than in simple rheumatic fever. Moreover, the pulmonary 
complications are frequently latent, and would be overlooked but for 
the daily physical examination of the chest. On the other hand they may 
develop with great suddenness, and what appeared to be a full-blown 
pneumonia may subside suddenly as a fresh joint is affected. They 
behave more like sudden active congestions than true pneumonias. 
Rheumatic pleurisies are characterized by the rapidity with which effu- 
sion takes place, the persistence of pain in the side during effusion, the 
tendency to involve both sides in succession, the readiness with which 
the effusion is absorbed, and their acute course. 

Nervous System. The most common complication of the nervous 
system is delirium, which is generally associated with insomnia and 
hyperpyrexia, but the latter is not constant. These brain-symptoms 
generally appear in the second week of illness, and about the time of 
convalescence, or while the joints are still inflamed. The delirium 
may be low and muttering, accompanied by ataxic symptoms or even 
by tremors and spasms of muscles ; or it maybe furious. In favorable 
cases a deep sleep ushers in recovery ; or, in unfavorable cases, the 
delirium persists with adynamia, the patient dying in collapse or coma, 
preceded or not by convulsions. 

Chorea sometimes occurs as a complication, but it is more common 
as a sequel of mild cases in children. Cerebral meningitis occurs occa- 
sionally, especially when there is ulcerative endocarditis. Cerebral 
embolism is another rare complication. 

Various spinal symptoms occur in some cases, at times with, and at 
times without, demonstrable lesion of the cord or its membranes. 
Tetanus, myelitis, and spinal meningitis may all be simulated. Per- 
haps these symptoms are due to high temperature ; but very high tem- 
peratures are met with without the occurrence of any cerebral or spinal 
symptoms. 

Nephritis is rare, but sometimes hemorrhage into the kidney occurs 
with its usual symptoms. Peritonitis is extremely rare. 

Various erythematous skin-eruptions are seen from time to time, 
and occasionally purpura. Subcutaneous nodosities have been described 
by several writers. They are attached to the tendons, fascia, and peri- 
osteum, and are most frequent on the back of the elbow, the ankles, 
and patella. They are painless, and may occur in any form of rheu- 
matism. 

Diagnosis. Rheumatic fever is distinguished from gout by the 
profuse acid and acrid sweating, the tendency to involve a number 



182 GENERAL DIAGNOSIS. 

of joints, and particularly the larger ones, by the greater intensity of 
constitutional symptoms, by the great liability to heart-complications, 
and by the absence of uric acid from the blood. 

It is distinguished from pyaemia by the wandering character of the 
inflammation ; the acid sweats ; the absence of any antecedent condi- 
tion which would develop purulent foci — such as injuries, abscesses, or 
specific eruptive fever ; the absence of chills, and the fact that in rheu- 
matic fever the sweats are constant, whereas in pyaemia they follow a 
fall in the temperature. Cutaneous abscesses do not occur in rheuma- 
tism, and after its subsidence the joint's usefulness is not impaired. 

Acute synovitis resembles rheumatic fever, because in both occur 
symptoms of pain, tenderness, and swelling in connection with a joint. 
Usually, however, in synovitis but one joint is involved, and there is 
a history of exposure to cold or injury. The effusion is limited to the 
synovial sac of the joint, is frequently abundant, and fluctuation can 
easily be detected. The constitutional symptoms are much less marked 
than in rheumatism. 

Milk-leg, or phlegmasia alba dolens, differs from rheumatism in that 
it usually occurs in women after confinement, or as a complication or 
sequel of fever, as typhoid fever. Usually one leg is affected, or part 
of the leg, especially the calf. This becomes tense, tender, uniformly 
swollen, and the seat of great pain. The leg is moved with much diffi- 
culty. The femoral vein may be found to be knotted and tender. 
There is almost always evidence of antecedent disease. 

Acute periostitis when close to a joint simulates rheumatism. But 
the tenderness and heat are not in the joint itself ; they are superficial, 
and are associated with less swelling. Pitting on pressure is common ; 
and circumscribed fluctuation usually discloses the presence of suppu- 
ration. Pysemic symptoms are added to the local symptoms, particu- 
larly if osteitis or osteomyelitis is present. 

The articular symptoms of glanders are to be distinguished by the 
occupation of the patient, the mode of onset, the associated symptoms, 
especially one or more pustules, and the fact that the painful joints are 
not so apt to be swollen and red as in rheumatic fever. 

In syphilis joint-pains frequently occur, but their character is made 
out by the fact that the joints are not inflamed, and that the pain is 
much worse, or occurs only at night, and by the history of the patient 
and the therapeutic test. 

In some diseases of the brain and spinal cord joint-inflammations of 
trophic origin occur. They are distinguished by the coexistence of 
some lesion of brain or cord, with hemiplegia or other palsy, and of 
other trophic changes, such as bed-sores, atrophied muscles, loss of 
hair, shiny skin, and defective growth of nails. 

Subacute Articular Rheumatism. 

In some instances the joint-inflammation is less severe, and is 
accompanied by only slight fever. One or more joints may be affected. 
It differs from the ordinary form in being milder in degree and more 
persistent, lasting sometimes for months. It is generally subacute from 



THE DATA OBTAINED BY OBSERVATION. 183 

the beginning, but may be the type present in those who have had 
several attacks of rheumatic fever and have been left in a very sensi- 
tive condition. Rheumatic fever is usually subacute in children, and 
often only one joint is involved. Cardiac complications are more fre- 
quent than in adults, and chorea may occur as a sequel. Erythema 
nodosum and subcutaneous nodosities are more common in children. 

Chronic Articular Rheumatism. 

In this form the patient has pain and stiffness in one or more joints, 
or in the contiguous tissues. The joints most frequently affected are 
the shoulder and knee. The pain is more or less constant, but worse 
in damp weather or on the approach of a storm, and worse also at 
night in many cases. Conversely, it is better in warm, dry weather. 
There is not much if any tenderness, and rarely any swelling or ele- 
vation of temperature. The joints very frequently crack and grate on 
motion. In the interval between the attacks there is no impairment 
of the usefulness of the joints. In very chronic cases there may be 
some atrophy of muscles and permanent stiffness, even fibrous anchy- 
losis. 

In some cases there are repeated attacks of subacute articular rheu- 
matism, accompanied by the usual symptoms and joint-effusions. 

Chronic articular rheumatism is distinguished from ehronic gout by 
the fact that there is no special tendency to involve the great toe, by 
the absence of the deformities resulting from gout, and the absence of 
deposits of sodium urate in the ears, fingers, and around the joints. 

Gout. 

A disease characterized by specific arthritis, associated with uric 
acid in the blood and the deposit of sodium urate in the joints, or 
manifesting itself as a diathesis in which occur other inflammations of 
non-articular tissues and various disturbances of functions of organs, 
the blood also containing uric acid. 

Gout is common in Europe, particularly in England, but in its ar- 
ticular form is rare in this country. There is an hereditary predispo- 
sition in from 50 to 60 per cent, of the cases. It results from over- 
eating of rich foods and the drinking of malt liquors, associated with 
insufficient exercise and excretion. Garrod has called attention to its 
association with lead-poisoning. Paroxysms are induced by indiscre- 
tions in eating or drinking, by nervous shock or great mental strain, 
by exposure to cold or injury, or by overwork and sexual excesses. 

The characteristic phenomena of gout are preceded for a variable 
time by acid flatulent dyspepsia, colicky pains in the stomach and 
bowel, constipation alternating with diarrhoea, and scanty, heavily 
loaded urine. Accompanying these dyspeptic symptoms often are 
impairment of physical and mental vigor, irritability of temper, and 
hypochondriasis. 

In other cases the premonitory symptoms are palpitation of the heart, 
or dyspnoea resembling asthma, or various nervous symptoms, as drow- 
siness, insomnia, or headache. 



184 GENERAL DIAGNOSIS. 

In acute articular gout the onset is often sudden, especially in the 
first attack. The patient may go to bed in apparent health, but wake 
up early in the morning with a feeling of discomfort or uneasiness, 
usually in the great toe. In some cases the pain is agonizing from the 
first. The patient finds he is unable to step upon the foot without 
torturing pain. The ball of the great toe is hot, swollen, red, and 
exquisitely resentful of the slightest touch or jar of the bed. The 
veins are swollen and the joint stiff. There is slight fever, perhaps 
chilliness, thirst, coated tongue, constipation ; scanty, high-colored urine, 
depositing urates on cooling ; the skin is warmer than normal, and 
there is slight perspiration. The pain usually abates during the day 
and increases at night. It is aggravated by motion and attended by 
painful muscular cramps. By the end of the first day or two the swell- 
ing increases and the pain lessens, owing to diminished tension of the 
part. Pain on motion is still great, however, and without treatment 
may continue for a week or two ; under treatment the paroxysm sub- 
sides in four or five days. 

Both great toes may be attacked in the first seizure, more often 
alternately than simultaneously, and sometimes other joints than those 
of the toes are affected. 

After the subsidence of an attack the urine contains a larger quan- 
tity of uric acid, and the patient feels better in health and spirits than 
for some time. A second attack may be postponed for several years, 
but usually after that the intervals between them steadily diminish, 
until an attack recurs every few weeks or months, and the patient 
may be scarcely ever free from it. Other joints than the toes, particu- 
larly those of the fingers, become involved in subsequent attacks. 

The Blood. INeusser has attributed to gout and the uric-acid diath- 
esis the presence of granules, observed after staining, in the white 
corpuscles, but they have been found in other affections, and are not 
diagnostic. The nature of many otherwise obscure gouty manifesta- 
tions or arthritic changes may be determined by an examination of the 
serum of the blood. Collect the serum which accumulates in a blister 
and examine for uric acid. (See Blood.) 

Chronic gout results from repeated acute attacks. It is characterized 
by deformity of the affected joints, around which are deposited chalk- 
stones (tophi) of sodium urate. Similar deposits occur in the helix of 
the ear. The first appearance is that of a clear vesicle under the skin, 
which subsequently becomes chalky- white and solid. The deposits of 
sodium urate occur not only in the cartilages of the joints but in the 
ligaments and bursa? also, resulting in great impairment of motion and 
deformity. " In extreme cases an appearance is presented by the 
hand very closely resembling a bundle of French carrots with their 
heads forward, the nails appearing to take the place of the stalks'' 
(Gar rod). 

Gouty abscesses consist of collections of liquid and solid sodium urate, 
which discharge, with or without pus, through the skin. A patient 
may have a number of them with but very little impairment of the 
general health. They may even act as a helpful vent to the system. 

In so-called retrocedent gout the external joint-manifestation is sup- 



THE DATA OBTAINED BY OBSERVATION. 185 

pressed or replaced by an internal inflammation, as one of the serous 
membranes. 

Gout attacks the nervous system, causing headache, delirium, and 
sometimes apoplexy, apoplectiform seizures, epilepsy, mania, various 
neuralgias, and spinal symptoms. 

It also affects the heart and bloodvessels, causing valvulitis and chronic 
arteritis. 

The symptoms presented by the digestive organs have been men- 
tioned. They are often premonitory of an attack. 

The kidneys may be affected, causing typical contracted kidney, or 
there may be chronic cystitis and urethritis. 

Rheumatoid Arthritis. 

Rheumatoid arthritis, or rheumatic gout, is an affection characterized 
by acute or chronic inflammation of the joints, of progressive charac- 
ter, and resulting in deformities. It is attended with very little fever, 
and occurs apart from any known systemic disease. 

It may be acute or chronic. The acute form differs but little in its 
manifestations from acute rheumatic fever. Several joints are en- 
larged, tender, and painful. Constitutional symptoms, such as fever, 
loss of appetite, frequent pulse, thirst, and furred tongue, occur as in 
rheumatism. Profuse acid sweats, however, are absent, and so is the 
tendency to serous inflammations. Moreover, while the larger joints, as 
in rheumatism, may be affected, the smaller ones also, especially of the 
fingers and toes, are inflamed and often the seat of serous effusions. 
Furthermore, the inflammation persists in the affected joints and does 
not jump from one to another. Instead of disappearing in a few 
weeks, it drags on for a much longer time. The pain subsides, but 
the swelling persists, and permanent deformity results in at least some 
of the joints. The muscles of the arms and legs waste and are affected 
with painful spasms. 

The disease is most common in young women exhausted by repeated 
pregnancies or prolonged lactation, and is favored by poverty, priva- 
tion, and cold. 

The chronic form is much more common. It also attacks most fre- 
quently young women who are exhausted or are subjected to great 
fatigue. There is pain, numbness, or formication in a joint, as the 
knee. The joint becomes tender, painful, and may be slightly swollen. 

This subsides after a while, but sooner or later the same joint or 
another one becomes affected, the process is persistent, one joint after 
another is attacked, and gradually all the joints may become greatly 
distorted, enlarged, and the seat of contractions. There may be no 
impairment of general health, or, at most, only dyspeptic symptoms. 
The progress is interrupted by remissions from time to time. Pain 
may be severe and subject to nocturnal exacerbations. The shape of 
the joints is altered by the effusion into the joints and adjacent bursse, 
by thickening of the tissues around the joints, growths of new bone on 
the joint-extremity of the bones, absorption of the articular cartilages, 
and growths of new cartilage in the synovial sheaths, relaxation of 



186 GENERAL DIAGNOSIS. 

ligaments, muscular contractures, and luxation of the joints. The 
joints crack and creak like rusty hinges, are sore and stiff, and the 
attached muscles are affected with painful cramps. (See Fig. 29.) 

Fig. 29. 




Rheumatoid arthritis. 



Great enlargement of the joints at times occurs from the causes 
already mentioned and from infiltration of the overlying tissues. The 
enlargement is rendered more conspicuous by the atrophy of adjacent 
muscles. (See Fig. 14.) 

In addition to the articular symptoms other phenomena attend the 
process. One of the more common is increased frequency of the pulse. 
Although the patient is afebrile, the average pulse-rate is 100 to 120, 
or even more. Moreover, the pulse is soft and compressible, in con- 
tradistinction to the pulse of gout and rheumatism. It is worth noting 
that a return to the normal frequency of pulse is a sign that the pro- 
cess of the disease is arrested, although the joint-lesions remain. 

The shin is characteristic. It is soft and often much freckled, while 
the complexion is fair. C. T. Griffiths has observed the pigmentary 
cutaneous changes, along with neural symptoms, prior to the joint- 
manifestations, and describes two forms : a diffuse melasmic discolora- 
tion, and dark-brown spots resembling moles, but not raised. Moist- 
ure of the skin with clamminess is common. It is limited to the palms 
of the hands, or may occur in the distribution of certain nerves. The 
sweats are not acid ; they are usually local, but may be profuse. Pain 
independent of the joint-lesion is due to neuritis, and may precede the 
joint-trouble. It is not merely confined to the nerve-trunks, but affects 
the smaller branches which are distributed to muscles, as the base of 
the thumb. Numbness and tingling are often present. 

The progress of the disease is pretty steadily worse. In extreme 
cases not only are the limbs crippled, deformed, and helpless, but there 
is fixation of the cervical spine and of the articulations of the jaw, so 
that the patient cannot move the head or masticate food. 



THE DATA OBTAINED BY OBSERVATION. 187 

The following describes the characteristic deformity of the hand : 
The first phalanx of the fingers is either flexed npon the metacarpus or 
extended, and the terminal phalanx in like manner is either markedly 
flexed or extended upon the second, or these two phalanges are kept 
at a straight line, while the first phalanx is, as usual, decidedly flexed 
upon the metacarpus. The hand is pronated and the fingers turn 
toward the ulnar side (Palmer Howard and Charcot). (See Fig. 29.) 

The foot is abducted and flattened, and the great toe abducted across 
and above the other toes. Rarely it may be beneath the other toes. 
The metatarso-phalangeal joint is enlarged. 

A variety of the disease is sometimes met with, chiefly in old persons 
(senile arthritis), in which the tendency is to involve one or two joints, 
particularly the hip, or hip and knee. It is of slow progress, and is 
otherwise attended with the same deformities as the usual polyarticular 
form. 

Rheumatoid arthritis is distinguished from gout by the absence of 
heredity and by its development under the exhausting influences of 
repeated pregnancies, lactation, poverty, and malnutrition. Rheuma- 
toid arthritis is progressive, with occasional remissions ; gout occurs 
in successive attacks, with intermissions. Uric acid is absent from the 
blood in the former and is present in gout. Rheumatoid arthritis in 
the vast majority of cases is subacute or chronic. The acute form is 
distinguished from acute gout by the duration of the paroxysm and the 
absence of intermissions ; by there being less heat, swelling, and red- 
ness of the joints, and less infiltration of the soft parts ; by the fact 
that large and small joints are involved, and that there is no special 
tendency to inflammation of the great toe. 

From chronic gout rheumatoid arthritis is distinguished by the 
absence of hereditary predisposition, of repeated acute attacks, and of 
the causes of gouty paroxysms — indulgence in sugars, acids, malt 
liquors, etc. Moreover, rheumatoid arthritis most frequently begins 
in the hands, and is symmetrical and bilateral. Gout has a predilec- 
tion for the great toe, and is unilateral. Again, gout attacks well-fed 
males most frequently after the age of thirty years, while rheumatoid 
arthritis tends to attack women under the depressing influences already 
mentioned. It may, however, occur in both sexes, and even be asso- 
ciated with gout. 

Rheumatic fever is distinguished from acute rheumatoid arthritis by 
its tendency to involve the larger joints, its erratic course, acid sweats, 
and heavy deposits of urates from the urine, its shorter course, its ten- 
dency to heart-complications, and its subsidence without impairment of 
the usefulness of the joints. 

Chronic articular rheumatism is distinguished by the preceding his- 
tory, the tendency to seasonal exacerbations, by its involving fewer 
joints, and not being so symmetrical in the joints affected. It does not 
produce so great deformity as is common in rheumatoid arthritis, nor is 
it so likely to affect the vertebrae and jaws. The existence of valvular 
heart disease or a history of antecedent chorea is in favor of rheumatism. 

The joint-affections of locomotor ataxia are distinguished by the asso- 
ciated symptoms of incoordination and absent knee-jerk, by their 



188 GENERAL DIAGNOSIS. 

sudden onset without pain or fever, by the occurrence of large effusion 
into the joint, with subsequent disorganization, fractures, and dislo- 
cations. 

Gonorrhoea! arthritis is distinguished by the history of gonorrhoea 
or the existence of a discharge from the urethra, by the tendency of 
the disease to attack the larger joints, particularly the knee or shoul- 
der, and to become fixed in one, not wandering from one to another. 
The affected joint suffers effusion, and the synovial membranes and 
bursoe are inflamed. The process is very chronic but indolent, and 
the heart rarely becomes affected. 

Scurvy. 

The joints are swollen, painful, and tender in about one-third of all 
cases of scurvy. When to these joint-symptoms the spongy gums, the 
hemorrhages, the anaemia, and cachexia are added, scurvy may be 
suspected. 

Scorbutus, or scurvy, is a constitutional condition brought about 
by a long-continued diet deficient in fresh vegetables. It is character- 
ized by pallor, great physical weakness and mental sluggishness,, 
dyspnoea, subcutaneous and submucous hemorrhages, a swollen, spongy 
condition of the gums, and a brawny induration, especially of the calves 
and hams. 

The onset of the disease is gradual, and is marked by a peculiar 
dirty-yellow or greenish pallor of the face, associated soon with an 
apathetic expression of the face, physical weakness, and decided lack of 
customary energy. The appearance is so characteristic that patients 
are said to detect it readily in others, though unaware of it themselves. 
Sleep and digestion are good, but rheumatoid pains may be complained 
of. Other prominent subjective symptoms are fatigue on slight exer- 
tion, dyspnoea, faintness, and despondency. In the course of a week 
or two petechia) appear upon the lower extremities, especially around 
a hair as the centre. (See page 128.) Depending upon the severity of 
the case there are also bullae, vibices, and ecchymoses. Brawny indu- 
ration, due to deep effusion of blood, occurs, especially in the calves 
and hams, producing considerable pain on flexure of the knees. 

There is no fever apart from complications. The pulse is frequent, 
weak, and small, and the first sound of the heart and the impulse may 
be very faint. 

The face is swollen and of a dirty, possibly greenish-yellow color, 
according to Bird, Buzzard, and others ; in some cases the eye and its 
surroundings are the only parts exhibiting signs of scurvy at this time. 
" The integument around one or both orbits is puffed up into a bruise- 
colored swelling. The conjunctivae covering the sclerotic is tumid and 
of a brilliant red color throughout, and about an eighth of an inch in 
thickness or elevation above the cornea, leaving the cornea at the 
bottom of a circular trench or well." 1 The condition is not inflam- 
matory. These cases often terminate fatally. 

1 Buzzard: Keynolds' System of Medicine, 1880, vol. i. p. 451. 



THE DATA OBTAINED BY OBSERVATION. 189 

The gums swell almost always, become spongy, and bleed upon the 
slightest irritation. They are dark cherry-red in color and look not 
unlike a split cherry. Sometimes they swell, so as almost to hide the 
teeth completely and even to protrude the lips. The breath has a 
heavy, sickening odor, and the teeth sometimes drop out of their sockets. 

In addition to the cutaneous and gingival hemorrhages, hemorrhages 
occur from the nose and other mucous surfaces, and effusions take place 
into the lungs, intestines, pericardium, and pleura, associated with in- 
flammatory products. There may be no physical signs on the part of 
the lungs to account for the dyspnoea, or some dulness and bronchial 
breathing, or a few rales, may be detected. 

A very peculiar symptom, and sometimes the earliest, is hemeral- 
opia, nyctalopia, or night-blindness, in which the patient can see during 
the day but not by moonlight, and apart from artificial light is totally 
blind at night. 

So-called scurvy-rickets is more or less common in infants fed on arti- 
ficial food exclusively or on sterilized milk. It is therefore limited 
to the first four or five years. The symptoms of scurvy are added to 
those of rhachitis. In the eight cases I have seen, the most pronounced 
features were those of weakness, anaemia, polyuria, restlessness, the 
scorbutic gums, local periostitis, particularly of the tibia, sometimes 
periarticular inflammation, and always a general tenderness of the 
body, as in rhachitis. 

The Tabetic Joint. In forms of nervous diseases, particularly in 
sclerosis of the posterior columns, secondary joint-involvement some- 
times occurs. The change in the large joints is preceded by pain, 
stiffness, and inability to use them. Gradually nutritive changes take 
place. At first there is boggy swelling. The cartilages become eroded, 
the heads of the bone waste, the ligaments ossify, and irregular bony 
growths project. Wasting of the head of the femur is followed by 
dislocation. Sometimes an effusion takes place in the joints, and there 
may be periarticular oedema. The large joints are most commonly 
affected — the knee, hip, ankle, and elbow. Injury excites the abnor- 
mal atrophic process. When the tarsal bones and the articulations are 
affected the foot becomes flat, and the tarsal and metatarsal articulation 
and the tarsal bones project forward or backward. This is called the 
tabetic foot. 

The Joint of Hysteria. Symptoms of joint-disease are seen in 
hysteria. Pain and fixation of the joint are sometimes complained of. 
The joint rarely undergoes organic changes, but sometimes a plastic 
infiltration of the connective tissue outside of the capsule does occur. 
The hysterical nature of the pain and immobility are recognized by 
the absence of a cause for joint-lesion, the absence of fluctuation, or of 
signs due to erosion, by the association of the local symptoms with the 
phenomena of hysteria, but, more particularly, by the fact that con- 
traction and even wasting precede the joint-symptoms. In true affec- 
tions of the joint both occur after the joint has become diseased ; in 
hysteria muscular contraction will take place first. 

The knee is the joint usually affected. Care must be taken not to be 
deceived by local vasomotor changes of hysterical origin which may 



190 GENERAL DIAGNOSIS. 

be observed under the surface of the joint. This local increased tem- 
perature is not associated with general fever, however, while the vaso- 
motor changes indicated by the swelling of the skin, increased tension, 
and the shining appearance, with increased sensibility, are not per- 
sistent, but occur once or twice in the twenty-four hours. In a 
remarkable case of Mitchell's the local vasomotor change took place 
at night. The temperature of the knee which was affected increased 
three or four degrees, while the pulse remained at 80. The local symp- 
toms of heat, redness, swelling, tension, and increased pain passed 
away by three o'clock in the morning. The fact that the same symp- 
toms could be brought on by handling the knee, or by pressure upon 
the patella, pointed to its vasomotor origin. 

In joint-cases of hysterical origin the reflexes must be studied. 
They do not change, and the electrical reactions are normal, although 
there may be atrophy from disuse, but not to the degree that occurs 
in organic disease. The muscles may be contracted, but, as previously 
noted, the contracture is primarily a relaxation, which takes place if 
the tension is removed. Concerning these vasomotor changes, Sir James 
Paget' s expression, " A joint which is cold by day and hot by night 
is not an inflamed joint," is a safe guide to the recognition of an hys- 
terical joint. When the joint becomes hysterical after injury it is most 
difficult to ascertain its true nature. 

Special Joints. The three joints that should concern the student 
more particularly are the shoulder, hip, and knee. When symptoms 
are referred to either of these joints they should not be passed over 
lightly. Grave consequences have followed the attributing of hip- 
joint inflammation to rheumatism when it was of tuberculous origin. 
Not only has hip-joint disease been mistaken for rheumatism, but the 
mistake has even been made of considering the process to be going on 
in the knee instead of in the hip. This is because there is often flexion 
of the leg, and because pain is so often referred to the knee-joint. 

On the other hand, cases of hip-joint disease have been mistaken for 
suppuration in the pelvis or in the iliac fossa. Typhlitis or appendi- 
citis has frequently been mistaken for hip-joint disease. 

In the case of the shoulder- joint there is danger of confounding 
neuritis of the circumflex nerve, and consequent paralysis of the del- 
toid, with affections of the joint. Although the patient is unable to 
move the joint, it is still readily moved" by the physician, and the 
physical signs of joint-inflammation are wanting. 






CHAPTER XIV. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 
Chills ; fever ; subnormal temperature. 

THE TEMPERATURE. 

Before discussing the subject of fever, it is not illogical to consider 
chills. 

Chills. 

" Chills " vary from a passing " creep " or cold sensation, extending 
up and down the spine, to the " shake " or true rigor of one-half hour 
or even longer. In infectious diseases the milder form is of as much 
significance as the more severe. The rigor may be so violent and pro- 
longed as to terminate fatally. It must be distinguished from the 
algid stage of cholera and the coldness of collapse. The chill is 
attended by general tremor or shaking, chattering teeth, cold extremi- 
ties, pallid face, often parched blue lips and finger-tips. Notwithstand- 
ing the peripheral coldness and the extreme sensation of cold, the in- 
ternal temperature rises, and may be 104° to 107°. 

Clinically, a chill or rigor marks the onset of severe infection, as 
pneumonia. " Chills " are symptoms of some affections, as malaria. 
They are seen in the course of many diseases, as typhoid fever, tuber- 
culosis, and septicaemia. In typhoid fever they disclose the occurrence 
of a secondary infection or a mixed infection ; they may be due to 
antipyretic treatment by coal-tar remedies (Osier) or result from con- 
stipation. Endocarditis is attended by daily chills or they occur at 
irregular intervals. Pyaemia and septicaemia, purulent inflammations 
(infections), inflammations of the biliary or renal passages, stone in the 
biliary canal, or the pelvis of the kidney (see Intermitting Fever) are 
frequently attended by chills. The morphine habit gives rise to chills, 
with some fever. 

Fever. 

In conditions of health the body-temperature is maintained con- 
stantly at about 98.6° F. (37° C). This stability of temperature is 
due to the central regulating apparatus called the thermotaxic mechan- 
ism, which controls the production and the dissipation of heat. Fever 
is a condition characterized by an increase of temperature, with usually 
increased disintegration of nitrogenous tissue. The muscles and large 
glands, as is well known, are the chief seat of heat-production. Both 
heat-production and heat-dissipation are believed to be under the 
control of the nervous system, either through the motor nerves or 



192 GENERAL DIAGNOSIS. 

special nerves which pass with them to and from definite centres in 
the brain, called heat-centres. In conditions of disease this thermo- 
taxic mechanism may be altered, so that the normal temperature is 
increased or lessened. (1) There may be elevation of temperature 
from diminished dissipation of heat, though not necessarily increased 
nitrogenous disintegration and disordered function. Or (2) there may 
be increased production of heat with diminished dissipation, hence the 
temperature will naturally be higher than if increased heat-production 
were accompanied by normal heat-dissipation. (3) There may be in- 
creased heat-production and at the same time increased heat-dissipation, 
in which case there would be the increased waste of fever with or 
without any elevation of temperature. (4) It is possible that heat-dis- 
sipation may be greater than heat-production, or that the thermotaxic 
mechanism may be disturbed, so as to promote loss, in which case 
there will be subnormal temperature. 

Mode of Determination of Fever. The temperature of the body 
can be roughly estimated by the hand of the physician, but this method 
is open to many sources of error. The skin is at times hot, and gives 
a deceptive sensation of considerable elevation of temperature, whereas 
when tested by the thermometer the temperature is found to be but 
slightly or not at all above normal. So, too, when the skin feels cold 
and clammy in phthisis and during a chill from any cause, the actual 
temperature of the body is decidedly above normal, and may be as 
high as 103° or 104°. To insure accuracy, therefore, it is iioav almost 
the universal custom to employ clinical thermometers. They are of a 
convenient size and shape for insertion under the arm or into the 
mouth, rectum, or vagina. The better ones are provided with an inde- 
structible index, so that the mercury in the capillary tube remains 
stationary at the highest level to which it rose when the thermometer 
was in the mouth or axilla. When not provided with such an index 
the reading must be made when the thermometer is still in position. 

Thermometers vary in the accuracy with which they register tem- 
perature. The best ones are compared with an acknowledged standard, 
and sold with a slip of paper which gives their fractional variations 
from the standard. When the exact temperature is a matter of great 
importance, it should be taken in the rectum or vagina, as their tem- 
perature is more nearly that of the body. It is of advantage to take 
the temperature in the rectum of children or in patients who are coma- 
tose. This situation is also a good one to select when a bath is being 
administered. If possible, scybalous masses should be removed from 
the rectum. At least an incorrect reading may be obtained if the ther- 
mometer should happen to be plunged into the faeces ; this must be 
guarded against. From motives of delicacy, however, the axilla is to 
be preferred to the rectum and vagina on all ordinary occasions. The 
temperature it records is somewhat less than a degree below that of the 
rectum. The temperature of the mouth is above that of the axilla and 
below that of the rectum. It has some advantages over that of the 
axilla, being more accessible and recording the temperature more 
quickly and more accurately. Nevertheless, as the physician's ther- 
mometer is carried from patient to patient, some place should be 



THE DATA OBTAINED BY OBSERVATION. 193 

selected which is less capable of absorbing disease-germs than the 
month. The axilla is, therefore, by common consent the usual place 
for taking the temperature. Observe two precautions : (1) Before 
introducing the thermometer see that there is no undue moisture ; if 
there is, the axilla should be wiped dry, otherwise a lower than a true 
reading will be obtained. (2) See that the instrument is inserted into 
the armpit and does not project beyond the posterior fold, and that it 
is not caught in a fold of the undershirt or night-dress. After the 
thermometer is in position the arm should be brought gently across the 
chest and kept in that position until the instrument is withdrawn. 
The arm should not be held rigidly, as such muscular action increases 
the hollow of the armpit and may keep the sides apart, instead of in 
contact, as they should be to make a correct reading. The length of 
time required to take the axillary temperature will depend upon the 
instrument used ; generally from five to eight minutes are required. 
Some very delicate thermometers register in one minute, but they are 
too fragile for ordinary use. If the index is in such a position that it 
can be seen, it is proper to withdraw the thermometer when the mer- 
cury has ceased to rise for two minutes. 

The index, of course, must be shaken down to normal, or slightly 
below normal, before the thermometer is again ready for use ; and the 
instrument must be carefully cleansed after use. 

In children who are restless the temperature may be taken in the 
groin, as the folds of fat readily admit of completely enveloping the 
bulb of the thermometer. The height to which the mercury rises 
will correspond to the temperature of the axilla. The temperature of 
the urine corresponds exactly with that of the body, if taken when 
freshly passed and during the act, a method only applicable in the 
case of males. Sometimes this method of securing the temperature is 
resorted to, particularly in patients who may act as malingerers, when 
it is desirable to have the temperature taken in the physician's 
presence. 

If the mouth is selected as the place in which the temperature is to 
be taken, care should be exercised that the thermometer is placed 
under the tongue, or along its side between it and the lower jaw, and 
retained in position by the lips of the patient. If the teeth are set 
firmly on the thermometer, it may be broken, or, what is of still greater 
importance, it will be tilted out of position and a correct reading will 
not be obtained. The lips should be closed and breathing be carried 
on through the nostrils. Four to seven minutes is sufficient time to 
allow it to remain in position. The patient should not have taken ice 
or anything cold prior to the observation. 

Observations of the temperature should be made at least twice a 
day, in the morning and evening, and, as far as possible, at the same 
hour on successive days. It is frequently desirable to have the tem- 
perature taken every two or three hours, and sometimes at more fre- 
quent intervals. This is particularly the case if observations of the 
indications for, and the effect of, antipyretic treatment are to be made. 

In obscure cases the observations should be repeated at night as well 
as during the day. In this manner the presence of unsuspected tuber- 

13 



194 



GENERAL DIAGNOSIS. 



culosis may be revealed, or the occurrence of suppuration in some por- 
tion of the body definitely determined. It should not be forgotten, 
however, that the temperature may be taken too frequently for the 
patient's good, the disturbance of his needed rest being distinctly 
harmful. 

As the general range of temperature and its diurnal variations are of 
more importance than the absolute temperature at any one time, ther- 
mometers not perfectly accurate in their reading are still good enough 
for clinical and therapeutic purposes. 

Physiological Variations of Temperature. The temperature is 
subject to 'physiological variations. 1. It rises from seven or eight in 
the morning until seven or eight in the evening, at which time it 
reaches its maximum. It then begins slowly to fall, reaching its lowest 
point in the early hours of morning, between two and four. This 
diurnal fluctuation does not usually amount to more than a degree. 2. 
Exercise, etc. Violent exertion raises the temperature, and so does a 
heated atmosphere, cold having a contrary effect. 3. Age. In infants 
and young children, up to puberty, the temperature has a somewhat 
higher range, and is subject to greater variations than at a later period. 
In very old persons the temperature may be subnormal. The normal 
axillary temperature of adults is 98.6° F. The period in the twenty- 
four hours in which the temperature is at its lowest ebb is from 12 
P.M. to 4 a.m. It may then be subnormal. The writer has known 
an over-cautious parent to make this physiological fall the subject of 
meddlesome observation and ill-judged treatment. 

Pathological Variations of Temperature. An elevation of tem- 
perature above the normal, not to be accounted for by external heat or 
severe exhaustion, may be considered febrile, and is pathological. 
The range of febrile temperature varies from above normal to 105° or 
106° in ordinary cases. A range above 106° may occur, but is not 
usually compatible with life. Certain terms have been applied to 
various degrees of temperature, to indicate in a general way the degree 
of fever : 

Very low or collapse temperature. 



Below 

About 
Normal 

About 

About 

About 
Above 



35 c 
36 

36^ 

37 

37* 
38 

38* 

39 
39.] 

40 
40] 

41 



Cent.: 



95.0° 
= 96.8 

= 97.7 

= 98.6 

= 99.5 
=100.4 
=101.3 

=102.2 
=103.1 

=104.0 
=104.9 

=105.8 



Fah. 



Subnormal temperature. 

Normal temperature. 

Slightly above normal or sub-febrile temperatures. 

Moderately febrile temperature. 
Highly febrile temperature. 
Hyperpyretic temperature. 



( From Finlayson. ) 

The Degree of Danger. In general the degree of danger to the 
patient increases with the height of the fever, but the duration of the 
high fever modifies this greatly. A temperature of 106° on the second 
or third day of an acute lobar pneumonia is not rare, such cases fre- 



THE DATA OBTAINED BY OBSERVATION. 



195 



quently ending in recovery, while a temperature of 105° in the second 
or third week of typhoid fever is of much graver significance. Da 
Costa has reported a case of cerebral rheumatism in which the axillary 
temperature reached 110°, yet the patient recovered. In the case of 
injury of the spine, reported by Teale, the extraordinary temperature 
of 122° was recorded, and the temperature-range for days was between 
112° and 114°. The patient recovered. 



Fig. 30. 




Malarial intermittent fever. Quotidian type. 



The Types of Fever. Fevers are divided, in accordance with the 
character of their range, into certain definite types. The types may 



Fig. 31. 



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Malarial intermittent fever. Tertian type. 

be indicative of special processes. It is certain that the recognition of 
a peculiar type forms a positive aid to diagnosis. The fever that con- 



196 



GENERAL DIAGNOSIS. 



tinues for more than two days, in which the difference between the 
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Malarial intermittent fever. Quartan type. 

is known as intermittent fever. The paroxysms may occur daily, every 
second or third day, or once a week. When the paroxysms occur 
daily, the intermittent fever is of quotidian type (see Figs. 30 and 33) ; 
every second day, tertian type, one day intervening without fever (see 
Fig- 37) ; every third day, quartan type, two apyretic days intervening 

The Course of the Fever. Fevers frequently have a definite 
course, known as (1) the initial stage; (2) the fastigium ; (3) the 
period of defervescence. During the initial stage the temperature rises 
higher each hour (or if extended over days, each day) than the pre- 
ceding hour or day — in this latter instance interrupted by the daily 
fluctuations. The stage may last from a few hours, as in a paroxysm 
of ^ intermittent fever, to four or five days, as in typhoid fever. In 
this stage we have a chill such as characterizes the onset of an inter- 
mittent fever, or the recurrent chills or chilliness with headache and 
backache that attend the first four or five days of typhoid fever. 
During this stage, also, the heat-dissipation from the cutaneous surface 
is diminished and the total heat-dissipation is less. When the hand 
is placed upon the patient the surface will be found to be cool, whereas 



THE DATA OBTAINED BY OBSERVATION. 197 

the temperature in the mouth or rectum will be found to be far above 
the normal. The patient complains of the coldness or chilliness, and 
the low temperature of the surface is indicated by the shrunken hand, 
the pallid, pinched face. The peripheral arteries are contracted, and 
hence cause diminution in the amount of blood to warm the skin and 
to compensate for the loss by radiation and conduction. This peripheral 
contraction is the cause of the chilliness and the fall in the tempera- 
ture of the skin. 

During the second period of the course of pyrexia — the fastigium — - 
the temperature of the body attains the highest point, and remains 
almost stationary, or may vary but a degree or two between maximum 
and minimum. It may last a few hours or from two days to three or 
more weeks, during which time it may oscillate to the maximum point 
of the first day. The temperature of the surface of the body is about 
the same as that of the deep parts, particularly in cases of pneumonia, 
measles, and scarlet fever. In typhoid fever, acute rheumatism, and 
phthisis, during this period, there may be a difference in the external 
temperature and the temperature taken in the cavities, as the mouth 
or rectum. More or less antagonism between heat-production and 
heat-loss exists under these circumstances. The latter may be greater 
than the former, if the skin perspires freely, as in rheumatism. The 
temperature then remaining high indicates that the production of heat 
must be proportionately increased, and hence far greater than in the 
cases in which the external and internal temperature are nearly the 
same. (See Fig. 34 : the fastigium here occurs in the first three days. 
In Fig. 37 the fastigium lasts until the crisis.) 

In the period of defervescence the temperature falls to the normal. 
In this period an attempt is made by the economy to return to a physi- 
ological state, in which heat-production and heat-loss are evenly 
balanced. The state of pathological pyrexia has come to an end. 
The termination may be by crisis. (See Figs. 31 and 37.) When this 
takes place the perturbation of the thermotaxic mechanism must be 
very great, but the normal state is at once resumed. In other cases 
the termination is by lysis — the temperature falls a degree or two each 
day until the normal is reached. (See chart of Typhoid Fever.) It 
seems that the thermotaxic mechanism of health is restored with diffi- 
culty. In some cases, in the period of defervescence, the aberrations 
are very remarkable. It seems as if the thermotaxic mechanism which 
controls heat-loss was in a convulsive state. The temperature rises 
and falls irregularly, gradually resuming the normal only as the 
strength of the patient increases. 

The Mode of Onset ; Initial Stage. The onset may be sudden or 
gradual. 1. The sudden onset occurs in acute diseases, as tonsillitis, 
pneumonia, and gastro-intestinal disorders of children, in erysipelas, 
and in intermittent fever. Within a few hours the maximum of tem- 
perature is reached. (See Fig. 37.) 2. The mode of onset may be 
gradual. The initial stage is prolonged under these circumstances, as 
in cases of typhoid fever. (See chart of Typhoid Fever.) 

The Mode of Decline ; the Defervescence. A sudden fall of 
temperature at the termination of a disease is known as crisis, which is 



198 GENERAL DIAGNOSIS. 

also attended by copious perspiration, a " critical sweat/' or by the 
passage of a large quantity of urine, and sometimes by several large 
liquid stools. The pulse-rate and respirations fall correspondingly 
with the temperature. (See Fig. 37.) 

The defervescence may, however, occupy several days, in which case 
it is called lysis. In this case the sweating is less marked, but may 
recur for several days. The slowing of the pulse and respiration like- 
wise take place gradually. (See chart of Typhoid Fever.) 

Diseases of sudden onset usually terminate with sudden decline, and 
conversely in diseases with a prolonged onset the decline is also pro- 
longed. Many cases which naturally terminate by crisis may end by 
lysis. This irregular termination is usually due to a complication. 
(See Fig. 34.) For instance, in measles, pneumonia is usually the 
causal complication, while in pneumonia it is empyema or endocarditis. 

The Daily Range of the Prolonged Initial Stage and the Fas- 
tigium. The daily range of the temperature in fever generally corre- 
sponds to the normal variations. That is, the temperature is higher 
in the evening than in the morning. The difference in the daily range 
varies in the different types of fever — generally, as previously noted, 
the continued fevers show a smaller, the intermitting fevers a larger, 
difference between morning and evening temperature. 

Sometimes there is inversion of the normal range. The evening 
temperature is lower than the morning ; although a rare condition, 
this is of serious import. It is seen in the more severe cases of typhoid 
fever and occasionally in tuberculosis. 

Recrudescence. In many cases the fever returns after the temper- 
ature has fallen to the normal. This may occur from a number of 
causes. It may be from perturbation of the nervous system, on account 
of excitement, over-exertion, loss of sleep, or from indigestion. Slight 
aberrations, which in health would not modify the temperature, cause 
pronounced oscillations in illness. Recrudescence, further, may be 
produced by a relapse. After the afebrile period following typhoid 
fever, for instance, the temperature may rise and a full recurrence of 
the disease take place. 

The Symptoms of Fever. Pyrexia, or increased temperature, is 
not the only evidence of fever. The production of heat within the 
body is not due to increased tissue-change alone. It may be due, for 
instance, to increased oxidation of sugar, which is part of the substance 
of the body. Physiologists have found that a high temperature may 
take place, and yet the quantity of urea and of carbonic acid discharged 
may not be as great as that of a healthy person who is taking active 
exercise or who has eaten a large meal. It must be remembered, 
therefore, that it is not heat-production alone but alterations of heat- 
regulation which cause pyrexia and its phenomena. 

Wasting. Wasting of the body is a striking symptom of fever. 
There is no doubt that even in fever of moderate duration great wasting 
of the solid structures takes place. At the same time the blood wastes 
(see observations of Thayer) and the various fluids of the body are 
also diminished, hence the disorders due to diminished secretion of 
glands are prominent in the course of fever. Diminution of secretion 



THE DATA OBTAINED BY OBSERVATION. 19£ 

in the gastrointestinal tract, causing thirst, loss of appetite, indigestion, 
and constipation, indicates the wasting of the fluids. Scanty nrine of 
high color and specific gravity is due to the same cause. 

The Pulse-eate. Acceleration of the pnlse is one of the phenom- 
ena that attend pyrexia. While increased pnlse-freqnency is the rule, 
and is, in all probability, a result of the increase in temperature, other 
circumstances may cause a change in the pulse-rate in pyrexia. Thus, 
in basilar meningitis, although there may be a high fever, the pulse is 
not more frequent. On the other hand, some diseases, usually accom- 
panied by fever, as diphtheria and peritonitis, may be afebrile, and yet 
the pulse be very much accelerated. 

Aeteeial Texsiox. The rapidity with which the blood flows in 
fever and the arterial tension do not bear a due proportion to the accel- 
eration of the pulse. The true febrile pulse is not dicrotic. In the 
early stages of fever the pulse is large and hard, the arterial tension is 
high, and the vessels full. In the later stages arterial relaxation takes 
place, and the pulse becomes soft and feeble, and often small, with 
low pressure. The pulse is rapid, and dicrotism, or even hyperdicro- 
tism, now becomes a prominent feature. The heart beating rapidly 
empties itself incompletely and discharges less rather than more blood 
into the arteries. The impairment of the cardiac beat is no doubt due 
to the degenerations on account of the high temperature, and is not 
dependent upon any special febrile affection. Such changes also take 
place in the glands, particularly the liver and kidneys, and are known 
as parenchymatous degenerations, or cloudy swelling. These changes 
in the cardiac muscle may induce, in the later stages of fever, thrombi, 
and cause death from heart-clot. 

The Respieatiox. The respirations are increased in fever, proba- 
bly because of the close dependence of the regulating centre of respira- 
tion on that of the heart. The heated blood acts as a stimulant to the 
respiratory centre. As proof of this, the hurried respiration of pneu- 
monia ceases as soon as the temperature falls, notwithstanding the fact 
that the affected part of the lung remains hepatized. 

Ceeebeal Symptoms. Delirium and other nervous symptoms may 
attend fever. They are not dependent upon the increased temperature 
of the blood alone. Xo relation appears to exist between the intensity 
of the fever and the severity of the delirium. In relapsing fever a 
temperature of 106° occurs with the mind clear. In certain cases of 
typhoid fever a temperature of 103° is attended with marked delirium. 
If fever persists for a short time a low asthenic state, so-called adyna- 
mia, may develop. Because the symptoms resemble those of typhus 
fever, the term typhoid is also applied to them, and the condition 
about to be described is known as the typhoid state. The expression is 
dull and heavy, the capillaries of the face are congested. There are 
stupor and sluggishness of mental processes, so that the patient is slow 
in answering questions. The stupor is attended with low muttering 
delirium, and may be followed by complete unconsciousness. The 
pupils are contracted, the eye heavy and dull. The patient is so pros- 
trated that he slips down into the bed from the pillow. There is 
marked subsultus tendinum. The tongue, if protruded, comes out 



200 GENERAL DIAGNOSIS. 

slowly and is tremulous. It is dry and brown, and the mouth and 
teeth are covered with sordes. The sensibilities are blunted, so that 
food and drink are not asked for, or particularly relished if given. 
Involuntary discharges take place from the rectum and bladder, and 
the incontinence of retention of the urine arises. The pulse is small, 
feeble, and dicrotic, the heart-sounds are weak and feeble. The first 
sound becomes short and snappy like the second, or may be absent 
entirely. Venous stases take place in the dependent portions, particu- 
larly in the back of the lungs. » , . 

As oedema or hypostatic congestion advances the breathing becomes 
shorter and labored. More or less cyanosis then creeps over the gen- 
eral surface. The urine becomes more and more scanty and high- 
colored, contains albumin, and sometimes blood. 

The typhoid state may continue for many days, or even last two or 
three weeks, although not in so advanced a degree as has been described. 
It is more likely to supervene when there is excessively high temper- 
ature, but it also occurs in the course of a prolonged illness with a 
temperature of moderate degree — that is, 103° F. Although it is in 
all probability due to the direct effects of heat upon the nerve-centres 
and the organs of the body, yet there are cases in which the temper- 
ature is not high, and yet all the symptoms of the typhoid state super- 
vene. While the typhoid state is common to typhoid fever , it occurs 
also in pneumonia and septiewmia, and may even be seen in its most 
typical form in other conditions in which fever is not a pronounced 
symptom ; thus in urcemia, in the later stages of softening of the 
brain, in paresis, or in allied nervous diseases the symptoms of the 
typhoid state are most striking. In this class of cases it certainly 
cannot be attributed to the fever, but is, in all probability, due to the 
depressing effect on the nervous system of material which should be 
excreted from the body, a view which has been advocated by Murchi- 
son, Flint, and others. 

Ataxia, or the ataxic state, in fever is a condition the opposite of 
the adynamic, or typhoid state. In the latter there is weakness, while 
in the former there is exhibition of strength. In the latter the nerve- 
centres and the vital processes are depressed ; in the former they are 
stimulated. Ataxia as an exhibition of strength is characterized by a 
strong pulse and by active, violent delirium, so that it is almost impossi- 
ble to keep the patient in bed ; by evidence of great muscular strength. 
The face is flushed, bright-red in color ; the eyes injected, bright, and 
active. The tongue is furred, but is not necessarily dry or brown. 
The delirium may be constant or paroxysmal, and is often maniacal in 
character. The temperature of the body is high, and a sensation of 
intense heat is imparted to the hand when placed on the surface of the 
trunk. The patient may complain of a bursting, intense headache. If 
the ataxic state is not controlled after a few days, or at the most a 
week, the patient becomes exhausted and lapses into stupor, which 
may proceed to coma. In some forms, particularly in children, con- 
vulsions may accompany the excessively high temperature and be fol- 
lowed by coma. The so-called coma vigil may supervene. The same 
exhibition of strength is shown. Ataxia is seen notably in scarlet 



THE DATA OBTAINED BY OBSERVATION. 201 

fever, " cerebral " pneumonia, and in forms of typhoid fever. The 
peculiar behavior of the temperature and nervous systems in this affec- 
tion and in apex pneumonia, or so-called pneumonia of the cerebral 
type, have led observers to mistake such cases for actual cerebral 
disease. Frequently they have been admitted into insane asylums for 
supposed mania. The true nature of such cases is often mistaken, 
and, because of lack of attendants, the patients have jumped from the 
window or done violence to themselves in other ways. 

It is as difficult to determine the exact cause of the extreme pertur- 
bation of the nervous system in febrile ataxia as in adynamia. It may 
be due to a high temperature, acting on nerve-centres ; or to a poison, 
as the special toxin of the infection which has caused the fever. 

The presence of fever may be suggested by flushing of the face. 
This may be general or local. The local flush of phthisis and of pneu- 
monia has previously been referred to. Dryness and pungency of the 
skin occur in fever. In former times the sense of heat was given 
different attributes, said to be distinctive of various affections. Hence 
the terms calor mordex, etc. Thus the sensation to the hand of the 
heat in typhus fever was said to be peculiar and characteristic. The 
degree of fever was determined by the sense of touch. The thermom- 
eter has displaced this method of reckoning temperature. Sweating is 
a condition habitual in some fevers. It may occur throughout the 
course of the disease, or at certain stages only as instanced by the early 
morning or night-sweats of tuberculosis. In such cases it is cold and 
clammy. The same sweatings are common in the fever of deep-seated 
suppuration and in disease of the bones. Sweating in defervescence 
marks the occurrence of crisis. 

Headache and pain in the back occur in the acute specific 
fevers in the initial stage. One or both are nearly always present, but 
in different affections they have diagnostic significance. Thus severe 
pain in the back is more pronounced in tonsillitis and smallpox, severe 
headache in cerebro-spinal meningitis, and protracted throbbing head- 
ache in typhoid fever. 

Subnormal Temperature. A temperature below the normal may 
occur independently of fever. It may follow as a sequelae of the dis- 
eases with more or less prolonged pyrexia. It occurs in the course of 
wasting diseases, as in cancer, in starvation, at times in anaemia. It is 
seen habitually in myxoedema, and occasionally in diabetes. In cer- 
tain forms of tuberculosis it may extend over a long period of time, 
as in tuberculous peritonitis. (See chart under Tuberculous Peritonitis.) 
In cases of cerebral abscess the temperature is often subnormal. 

Sometimes the drop to subnormal temperature may occur suddenly, 
to be followed by a return to normal or even a rise above normal. 
The sudden fall may occur in shock, or in hemorrhage from any cause. 
It may take place from disturbance of the nerve-centres, as from 
apoplexy, thrombosis, or embolism of the brain, causing shock or other 
disturbance of the thermotaxic mechanism. It is characteristic of 
cholera. In the course of organic heart disease pulmonary embolism 
is also attended by subnormal temperature. In many of these in- 



202 



GENERAL DIAGNOSIS. 



stances the temperature will rise (reaction) after the shock if the latter 
is not too profound. This is notably the case in apoplexy and in 
embolus or thrombus, because of local irritation or a secondary soften- 
ing. In apoplexy the rise in temperature will occur either from cen- 
tral disturbance of the thermic mechanism or from secondary inflam- 
mation about the clot. A subnormal temperature in the course of 

Fig. 33. 





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Subnormal temperature. Oscillations in hepatic intermittent fever with jaundice. Catarrh of 
ducts, with diffused hepatitis. G. W., aged 60. Philadelphia Hospital, 1877. 



fever may be due to an accident or complication, as hemorrhage in 
disease of the lungs, or in typhoid fever, or perforation of the intestine 
in the latter condition. It may attend the crisis of acute disease. More 
or less collapse usually attends the pathological fall of temperature 
below the normal. While such fall is the result of accident in many 
of the diseases mentioned, in others it is a part of the process. 

The chart (Fig. 33) represents the effect of a local process in the 
largest gland of the body upon the general temperature. It is possi- 
bly a septic temperature, although the observation was made before 
the days of bacteriological research. The extreme low temperature is 
remarkable. 



THE DATA OBTAINED BY OBSERVATION. 203 

The Diagnostic Significance of Fever. Its Clinical Causes. 

The presence of fever is itself of diagnostic importance. 

A. It usually excludes hysteria and malingering disease. 

B. It indicates that one of several morbid processes is present. The 
morbid processes which give rise to fever are : 

First, an infection, general or local, as seen in any one of the infec- 
tious diseases and in the local inflammations induced by micro-organ- 
isms, especially those known as pus-producing. When local, the 
inflammation is known as purulent, suppurative, or septic. The micro- 
organism, a product of its growth, or the poisons or ferments resulting 
from the tissue change, disturbs the thermotaxic mechanism and causes 
fever. Any tissue, membrane, or organ of the body may be the seat 
of an infectious process. 

Second, an intoxication, or toxaemia, as caused by albumoses, ferments, 
toxins, or ptomaines, generated within the system, the result of im- 
paired functional activity of organs or structures, or of cell metabolism, 
as seen in tissue waste ; and by food products, medicines, or toxic 
substances introduced from without. Catarrhal inflammations cause 
a toxic fever. The fever of gout, of ansemia, of starvation is toxic. 

Third, fever may be of central origin, from disease of the brain in- 
volving the centres controlling heat, or from disease in proximity to the 
heat-centres. It may arise in cases of brain-tumor, in cases of apoplexy, 
and of thrombosis. The centres may also be irritated by direct ex- 
posure to external heat alone, or possibly by poisons generated within 
the system on account of the heat (an intoxication), as in sunstroke. 

Fourth, a pronounced peripheral irritation or sensation of pain, reflexly 
altering the thermotaxic mechanism, will produce fever. Hence, in iritis 
or orchitis a fever arises out of all proportion to the local inflammation. 

Finally, cases of continued fever exist that have not thus far been 
classified. One of the nurses of the Presbyterian Hospital with a 
continued temperature from 100° to 103° was under my care for two 
months. No general or local condition could account for it. The 
patient was emaciated. She had had two years of very hard work. 
Although fever kept up, the appetite was good. Careful and abundant 
feeding, with rest for many weeks, caused the temperature to fall to 
normal, with complete recovery. I looked upon it as a nervous fever ; 
an expression of exhaustion. Fagge refers to such cases. 

Practically, we must in all cases of fever decide between one of infec- 
tious and one of toxic origin. Discussion of the mode of determining 
the occurrence of an infection will be considered shortly. In the mean- 
time we may observe that the poisons which are generated in the 
gastro-intestinal tract are likely to disturb the cardiac and respiratory 
as well as the thermotaxic mechanism. Hence we often see irregu- 
larity and intermittency of the heart — so often as to look upon it as of 
diagnostic value in favor of toxic fever. 

Certain clinical features of a febrile course belong, in the main, to 
special affections, and thus far are diagnostic of them. Hence the 
mode of onset or initial stage, the course or fastigium, the decline and 
the type should be carefully studied. They are a most important in- 
dication of the nature of the disease. 



204 GENERAL DIAGNOSIS. 

The Initial Stage. 1. In the initial stage of fever sudden, ex- 
cessive rise of temperature from a condition of apparent health argues 
against any of the acute specific fevers except scarlet fever. It is of 
more frequent occurrence in acute gastric or gastro-intestinal catarrh 
in children than in any other ailment. It may be due to pneu- 
monia, and is significant of this infection in adults if attended by a 
rigor. In children convulsions may replace the chill. The sudden 
rise may be due to certain types of malaria, when it is also preceded 
by a chill and followed by free sweating. It may also be due to affec- 
tions of the throat, to follicular or phlegmonous inflammation of the 
tonsils. The throat must always be examined in cases of sudden high 
temperature. 

In children, if pain attends any inflammatory affection, the tempera- 
ture will rise to a greater height than the local process alone would 
warrant. This is the case with suppurative inflammation of the 
middle ear. This must always be borne in mind in sudden rise of 
temperature. The same active febrile reaction will take place in osteo- 
myelitis and in mastoid abscess. The associate signs point to the true 
nature of the affection, although it must be confessed that in both the 
symptoms are often obscure in the beginning. 

2. In typhoid fever the temperature rises in a characteristic way. 
It ascends by successive evening rises, followed by morning remis- 
sions, until it reaches the maximum at about the end of the first week. 

The Fastigium. In typhoid fever the course of the fastigium is 
of characteristic significance. From the end of the first, throughout 
the second week, and sometimes longer, the fever is of the continued 
type. Subsequently during the third week, or later, morning remis- 
sions set in, the temperature for a time still rising to the former height 
in the evening. Then the morning remissions become more decided, 
the temperature not rising as high in the evening, and so gradually 
the temperature sinks to and below normal. This course of the tem- 
perature in typhoid fever is very far from being invariable ; it is modi- 
fied by indiscretions on the part of the patient or his attendants, and 
by the necessities of antipyretic or other treatment ; nevertheless, the 
gradual onset of the fever and its long duration are sufficiently com- 
mon to make them of great value in diagnosis, as, with the exception 
of tuberculosis, there is hardly any other disease in which a continued 
fever exists for two or three weeks apart from local inflammation or 
suppuration. 

The Decline. Defervescence. In the self-limited diseases there 
is a period when defervescence should take place. A continuance of 
the fever, the persistence of the fastigium beyond the usual period, 
indicates that the case is one of a greater degree of gravity than usual, 
or that there is a complication. It is usually significant of a compli- 
cation. In measles the complication is usually pneumonia. This 
may take place after the disease has developed, and may be the cause 
of the unusual rise in temperature. In scarlatina it may indicate 
acute nephritis, or inflammation of any of the serous membranes, 
particularly the pericardium or endocardium. Persistence of the 
fastigium of typhoid fever after the period at which it should decline, 



THE DATA OBTAINED BY OBSERVATION. 



205 



if the patient is well nursed and properly fed, usually indicates the 
occurrence of a reinfection, a secondary infection, or the development 
of tuberculosis. If the latter, the fever is more likely to develop dur- 
ing convalescence. Of the inflammatory complications, phlebitis and 
glandular and bone infections are likely to cause persistence of fever. 

Fig. 34. 





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Scarlet fever. Modification of temperature by complications. Nephritis on the ninth day. 



A Sudden Fall; Subnormal Temperature. A sudden fall of tempera- 
ture in a person who has previously had high fever signifies the crisis 
if the time for that event has arrived, as in pneumonia ; or of a grave 
complication, which induces shock. In typhoid fever this unusual 
drop in the temperature will take place if there has been hemorrhage 
from the bowels, or perforation, or if peritonitis has developed. It 
must not be confounded with the sudden falls of temperature that 
occur in the typhoid fever of children, corresponding to the onset of 
convalescence. They occur earlier in the period of the disease than 
with adults. 

The Type of the Fever. Intermittent Fever. The representative 
of the type is seen in malaria, but it is simulated by a number of 
conditions : (1) In certain cases of typhoid fever and of relapsing fever 
the type is intermitting or paroxysmal. The same type of fever is 
seen (2) in suppuration, particularly if the pus is confined, although in 
brain abscess the temperature may be normal or subnormal ; (3) in 
infectious endocarditis; (4) in tuberculosis. a. It may occur in the 
earlier stages of tuberculosis. The primary seat of the lesion may be 
in the lungs, in the bones, or in the glands, b. In pulmonary tuber- 
culosis, after the formation of a cavity, intermitting fever is of common 
occurrence. It is then of septic origin due to the septic influence of the 
necrosed tissue and products of putrefaction in the cavity. (See Fig. 35.) 
(5) In lymphadenoma and anaemia the fever is at times paroxysmal. 



206 



GENERAL DIAGNOSIS. 



(6) In syphilis the same type is often seen. It may be noted (a) in the 
initial fever ; (6) in the tertiary periods of the disease where gummata 
have formed, or other forms of visceral syphilis have developed. (7) 



Fig. 35. 



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Intermitting fever of tuberculosis. 



Urinary intermitting fever is the form Avhich usually occurs after the 
passage of a catheter or sound, but it may also occur when there is 
suppuration in the genito-urinary tract. (8) Hepatic intermitting fever 
is a form of frequent occurrence and of great diagnostic importance. 



Fig. 




Continued fever of tuberculosis. 

It may be due to (a) gallstones somewhere in the biliary ducts, usually 
with obstruction ; (6) suppuration in the canal, with or without ob- 
struction ; (c) obstruction of the biliary passages by external pressure 
without suppuration ; (d) inflammatory affections of the liver, as ab- 
scess, and forms of cirrhosis. It occurs rarely in rapidly growing cancer. 
(See Fig. 33.) (9) Intermittent fever may also attend the prolonged 
use of morphine. 



THE DATA OBTAINED BY OBSERVATION. 



207 



Of the above-mentioned varieties of paroxysmal or intermitting 
fever, those of the most common occurrence are due to suppuration, 
pyaemia, to infectious endocarditis, to tuberculosis, and to hepatic dis- 
order. In addition to the paroxysmal temperature, rigors precede and 
sweating follows the paroxysm, as in cases of malarial intermittent fever. 



Fig. 37. 





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Pneumonia. Sudden rise. Termination by crisis. Pseudocrisis also seen. 

The diagnosis from malarial intermittent fever can be established at 
once by an examination of the blood, which reveals in the latter the 
plasmodia of Laveran. • 

Remittent Fever. Fever of a remittent type occurs in many of the 
conditions in which intermittent fever is present. It is characteristic 
of one of the forms of malaria. It is most frequently encountered in 
tuberculosis of the lungs. The remissions usually occur in the morn- 
ings, but the order may be reversed. The same type of fever is met 
with in puerperal fever, pysemia, and septicaemia, and in local suppu- 
rations, such as abscess of the liver and empyema. A continued fever 
may be made to resemble a remittent by antipyretic treatment, which 
may cause abnormal remissions. Remissions characterize the decline 
of the continued fevers, particularly typhoid, during the period of lysis. 

Continued Fever. Continued fever is met with in lobar pneumonia, 
typhoid fever, typhus fever, erysipelas, and tuberculosis. In acute 
lobar pneumonia the temperature rises rapidly, and in a few hours 
from the initial chill reaches 103° or 105°. The morning and even- 
ing temperatures vary but little, usually not more than one or two 
degrees, until a crisis occurs in from four to eight days. The temper- 
ature then falls to or slightly below normal, and does not rise again. 
(See Fig. 37.) 



208 GENERAL DIAGNOSIS. 

A marked remission in the fever sometimes occurs on the fourth 
day, before the actual crisis ; the temperature falls to 100°, and rises 
again to 103° or 104°, remaining at that level for twenty-four or forty- 
eight hours, when the true crisis occurs. The first fall is known as the 
pseudocrisis. The fall of temperature of defervescence (crisis) may be 
completed within a few hours. 

The Influence of Age and Sex. The significance of a high 
febrile change is not so great in children as in adults. That is, the 
high temperature is not so important, inasmuch as children are liable 
to have sudden, excessive increase of temperature ; and a higher tem- 
perature may persist in children without deleterious effects upon the 
tissues which are noticed in adults. In women of nervous tempera- 
ment the temperature is also likely to rise to a great height without 
adequate cause or serious result. 



CHAPTER XV. 

THE DATA OBTAINED BY OBSERVATION— ( Continued). 

FEVER. THE INTOXICATIONS. 

Practically, it may be said that the symptom fever may be due to 
an intoxication, an infection, or a central cerebral lesion. In this 
chapter a word may be said of the fever of an intoxication. The sub- 
stance which produces fever of this type may be a toxic material, the 
product of local or general disturbance of tissue metabolism. Thus in 
a local catarrhal inflammation, as of the bronchi, the result of the 
direct action of an irritant vapor, toxic substances are generated which 



Fig. 



Fig. 39. 



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Aseptic or fermentation fever. 

disturb the heat mechanism and 
produce fever. Now, an intoxica- 
tion or simple inflammation, there- 
fore, is attended by fever, which 
may be styled catarrhal fever. 
(See Fig. 41.) In anaemia, on the 
other hand, if all infections can be 
excluded, it may be said the gen- 
eral disturbance of tissue metab- 

Temperature curve after amputation of the forearm, olism pOSSlbly gives rise to the 

formation of a toxin which causes 
the fever well known to attend this process — ancemic fever. 

A better example of fever due to a poison is that which Collins 
Warren terms aseptie fever. It is also known as absorption or fermen- 

14 



210 



GENERAL DIAGNOSIS. 



tation fever. The fever follows a perfectly aseptic operation, and no 
causal factor is present. It is due to the absorption of ferments, from 
blood clot, or coagulated serum, or tissue debris. The temperature 
rises to 102°, and may remain above normal from three days to two 
weeks. (See Figs. 38 and 39.) There is a striking absence of consti- 
tutional symptoms, however. Another peculiarity is that the fever 
begins immediately after the operation. The urine is not lessened, the 
body- weight remains normal, and the pulse-rate corresponds to the 
temperature rise. In some instances an eruption like that of scarlet 
fever — surgical scarlet fever — breaks out. 

Should it happen that the retained fluids undergo decomposition and 
are absorbed, a more intense type of fever is seen, attended by marked 
constitutional symptoms. We then have traumatic fever — a fever which 
subsides as soon as the poison is liberated from the wound. In the 
meantime the temperature has been as high as 102° to 103° — the pulse 
very rapid, delirium has been marked, and there has been furred 
tongue, thirst, anorexia, restlessness, and malaise. 

It may happen that septic infection of a wound takes place. Thus, 
one of my patients, while dressing a suppurating vaccine wound, inoc- 
ulated or infected her finger. The ten- 
der spot was followed by redness along 
the lymphatics, and enlargement of the 
glands — a lymphangitis. She had fever. 
A deep cut in the infected spot released 
a serous discharge, the fever disap- 
peared, and the lymphatic inflammation 
subsided at once. Such accidents hap- 
pen frequently to surgeons. Another 
patient was infected by a surgeon who 
had just operated on an osteomyelitis. 
The temperature rose to 106.5° in twen- 
ty-four hours, and the constitutional 
symptoms were extreme. The wound 
in the abdominal walls was opened and 
cleansed, and the peritoneum was not 
reopened ; no peritonitis resulted. The 
temperature fell four degrees at once. 
The muscles and other tissues of the 
wound became grayish and almost pu- 
trid. Recovery was slow. Such cases are known as septic cases, the 
ailment septicaemia, and the intoxication saprazmia. (See Fig. 40.) 
No bacterial invasion of the body takes place, and there is no local 
suppuration. Xo doubt, in each instance micro-organisms infected the 
wound, but the symptoms arose from the chemical product resulting 
from their growth. 

In obstetric practice the retained putrefying placental fragment will 
cause such symptoms. In medicine we see such intoxication tal e place 
in infections. Thus in diphtheria, systemic intoxication with fever 
results from the absorption of a toxin from the local point of bacterial 
growth. In tetanus the same toxic fever and symptoms occur. It is 













Fig. 


40. 










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Septic intoxication. 



THE DA TA OB TAIN ED B Y OBSER VA TION. 2 1 1 

impossible to draw hard-and-fast lines between the toxic fever and the 
infective, pyogenic or suppurative fever, and, indeed, such cases prop- 
erly belong and will be considered under the next prominent causes 
of fever to be considered — the infections. 

But " fever " may be due to other intoxications. It is well known 
that pepsin and other digestive ferments injected into the body cause 
fever. It is supposed products of imperfect assimilation or digestion 
absorbed into the system from the gastro-intestinal tract give rise to 
fever. Ptomaines or leucomaines, albumoses or peptones, absorbed 
from the intestinal tract may thus cause fever. The retention of ex- 
cretory products, as those of the renal organs, cause a systemic intoxi- 
cation, with the frequent occurrence of fever. Gout, too, may be con- 
sidered as an intoxication giving rise to fever. 

The fever of auto-intoxication (gastro-intestinal or glandular), so 
called, therefore, is an entity. The clinician, at least, without proof 
by the bacteriologist, sweeps the intestinal tract with his mercurials and 
salines, and thereby administers the causal antipyretic. 

Poisoning by food products, as of cheese, meats, sausages, milk, etc., 
appear to cause fever, although it is possible intestinal bacteria may 
play some part in the process. 

Varieties of Febrile Intoxications. It is assumed that the student is 
investigating a case of fever. In keeping in mind an intoxication as 
a cause of fever, he must first consider all causes of intoxication from 
within ; second, all causes from without the organism. 

To the first belong gout, uraemia, cholestersemia, and the auto-in- 
toxications from the intestinal tract, as well as those from modification 
or suppression of internal secretions, as of the thyroid and other glands. 

To the second belong the following : Sunstroke, morphinism, and 
food-poisoning. The fever due to an intoxication, as in the so-called/e6ri- 
cula and in the simple continued or catarrhcd fever , is of doubtful origin. 

Diagnosis. The Action of the Heart. Increased frequency of car- 
diac action is a symptom common to all forms of fever. It is more 
common to see irregularity and intermittency in the fever of intoxica- 
tion, and especially of auto-intoxication, than in that of infections. 
Indeed, I should call a fever which is attended by a cardiac neurosis, 
cardiac mural disease and cerebral disease excluded, one of intoxication. 

Increased Respiration. The same may be said of the breathing. 
When a respiratory neurosis prevails in the course of fever, it and the 
fever attending are due to a common cause, an intoxication. Of 
course, pulmonary and central brain and medulla disease are excluded. 
It seems both the above observations aid in the diagnosis of an in- 
toxication from an infection. 

Febrile Intoxications. 

Sunstroke (siriasis, thermic fever, insolation, heatstroke). Whether 
the cause is the direct action of heat upon the brain centres, or whether 
a toxic substance is generated and becomes operative, in this affection 
we have the most pronounced expression of fever outside of the in- 
fectious disorders. The flushed face, the pungent skin, the dyspnoea, 



212 GENERAL DIAGNOSIS. 

and the rapid pulse forebode the high body temperature which in 
the axilla may reach 108° to 112°. This is reached very rapidly, 
and death takes place in coma hyperpyrexia. If recovery takes place, 
the temperature may be moderately continuous a few days. The pic- 
ture is added to by the nervous and cardiorespiratory phenomena. 
In some instances dyspnoea, heart-failure, and coma may follow on 
rapidly, and death ensue in one or two hours. In other cases pain 
in the head, dizziness, and languor precede the stupor. Nausea and 
vomiting, perhaps diarrhoea, chest oppression, frequent micturition, 
and convulsions may precede the insensibility. Unconsciousness is 
lost quickly or gradually, and it may be transient or pass into deep 
coma. Relaxation of the muscles with twitching is seen, and the pupils, 
at first dilated, become contracted. As the coma deepens, the heart's 
action becomes more rapid and feeble, the respirations hurried, shallow, 
and irregular, and death ensues, preceded or not by convulsions. 

The diagnosis is based on the history, the mode of onset, and the 
hyperpyrexia. It must be distinguished from uraemia and apoplexy. 

Heat exhaustion is readily recognized. The moist, pale, and 
cool skin, the soft, feeble pulse, the quiet bat hurried breathing, are 
unattended by fever. The collapse, for such it is, is not attended by 
coma, and it usually responds to treatment. 

Morphinism. Lewin showed that morphinism is attended by fever. 
The fever may be continued or intermittent. When the latter, chills 
are of frequent occurrence. The diagnosis is based on the history, on 
the evidence of poor nutrition without cause, on the general depression 
and lassitude, and upon the temperament of the patient, to which is 
added poor sleep, restlessness, and itching of the skin. The peculiar 
sallowness of the complexion and the prematurely aged appearance are 
well known. Pseudo-neuralgic pains are common, tabetic symptoms 
may be present, and notably gastro-intestinal symptoms, as gastralgia, 
vomiting, diarrhoea, especially if the drug is withheld. Fever, it 
must be remembered, may be absent. 

Simple Continued Fever. A non-contagious fever, lasting from 
one to twelve days, not dependent upon any known specific cause, and 
not attended with any definite local lesions. Its chief characteristic is 
the continued elevation of temperature. 

It occurs especially in children and in those prone to ready disturb- 
ance of the heat-regulating apparatus. Great mental and physical 
exhaustion, prolonged bathing in the hot sun, and disturbances in 
digestion may cause it. Perhaps, as suggested by Guiteras, some of 
the cases occurring in the tropics and in very hot weather should be 
regarded as very mild forms of thermic fever. 

The onset of the disease is abrupt. There may be a chill, or in ner- 
vous children a convulsion ; but these are rare. The temperature rises 
rapidly from 102° to 104°, accompanied by headache, thirst, restlessness 
or drowsiness, loss of appetite, a coated tongue, constipation, and occa- 
sionally nausea. The urine is scanty, and sometimes there is a heavy 
deposit of urates. There may also be more or less muscular soreness. 
Sometimes within twenty-four or forty-eight hours free perspiration 
takes place, with rapid subsidence of the fever. This is ephemeral fever. 



THE DATA OBTAINED BY OBSERVATION. 



213 



In other cases the fever continues for a week or ten days longer. 
During this time the symptoms already noted continue. Sleep is dis- 
turbed and mild delirium is at times present. Respiration and pulse 
are not much accelerated. Sudamina upon the abdomen and herpes 
on the lips are common. Pale-bluish maculae are sometimes seen. 



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Simple continued fever. 



The spleen is not enlarged except in very rare cases, and there are no 
local evidences of disease. The fever subsides more gradually than in 
ephemeral fever, the defervescence being marked at times by perspira- 
tion, a few loose stools, a copious deposit of urates in the urine, or by 
hemorrhages from the nose, rectum, uterus, or urethra. 

The diagnosis from other fevers and febrile affections is made by the 
absence of any characteristic eruption, of enlargement of the spleen and 
liver, and of any lesion, such as endocarditis, bronchitis, or pneumonia. 

Food Intoxications. Among the intoxications which give rise to 
fever are those due to food-poisoning. Meat, milk products, and shell- 
fish cause an intoxication of the system which in the instance of the 
first three forms often threatens life, and, from the suddenness of the 
attack and the severity of the symptoms, points to an infection rather 
than an intoxication. 

The history of the case is often the first clue to its nature. The 
symptoms are those of acute gastro-intestinal irritation, to which are 
added, with or without afebrile periods, the symptoms of collapse. 

Meat-poisoning. In the intoxication arising from poisoning by 
meat, the temperature rises from 101° to 104°, preceded usually by a 
brief period of chilliness. The occurrence of fever may be preceded 
by a period of incubation lasting from twelve to forty-eight hours. 
During the period of incubation there is malaise, loss of appetite, 
nausea, and colicky pains. As they increase chilliness ensues, and in 
some instances there is a marked rigor. Prostration occurs almost 



214 GENERAL DIAGNOSIS. 

immediately, with giddiness and faintness, and the occurrence of cold 
perspiration. Headache and backache are liable to occur. Following 
the chilliness the symptoms of gastro- intestinal irritation arise, diar- 
rhoea being more frequent than vomiting. The abdominal pain in- 
creases and the perspiration and clammy sweats become more pro- 
nounced. As further evidence of the intoxication, there is an extreme 
degree of muscular weakness. The pulse becomes rapid, and later, 
thready. In addition to muscular weakness, cramps in the legs and 
arms, followed by convulsive movements, occur, and the patient com- 
plains of paresthesia of various forms. In milder cases the symptoms 
of gastro-intestinal irritation and of muscular weakness attend the 
fever. In the more severe cases fever is replaced by collapse. 

Poisoning by Milk Products. Symptoms of gastro-intestinal irri- 
tation and choleraic symptoms ensue. The diarrhoea of infants and 
cholera infantum are types of this intoxication. The high degree of 
fever that occurs is well known. In cheese-poisoning the fever is not 
continuous as in the other forms, the temperature becoming subnormal 
with the onset of collapse. 

Poisoning by Shell-fish. In mussel-poisoning the symptoms are 
those of an acute mineral poisoning with profound nervous symptoms. 
Fever does not attend this condition, but collapse follows quickly. 
There are no gastro-intestinal symptoms. 

Fish-poisoning is also unattended by fever, collapse occurring early. 

Afebrile Intoxications. 

For convenience, and by contrast, the afebrile intoxications will be 
considered. Herein will not be considered those important afebrile 
intoxications due to disease of the ductless glands. They include some 
diseases of the suprarenal bodies (Addison's disease), the thyroid gland 
(exophthalmic goitre and myxoedema), the lymphatic glands (status 
lymphaticus), and the spleen. 

Alcoholism. In acute alcoholism the reeling gait, the incoherent 
speech, followed by narcosis, are well known. The temperature is 
afebrile. Often, indeed, it is subnormal, and when equal on both sides 
of the body is very suggestive. The flushed face, possibly slightly 
dusky, and the injected eye, would lead us to suspect the presence of 
fever. The odor of the breath furnishes a clue. The heavy breath- 
ing, the full pulse, the dilated pupils, the stuporous rather than coma- 
tose state, are accompaniments of this intoxication. The flaccid limb 
of one side would point to hemiplegia from hemorrhage, especially if 
the coma is deeper than usual and the stupor more marked. But 
urcemia and apoplexy, and either of the two in a drunken subject, must 
be borne in mind. 

Chronic Alcoholism. AVhen the poison is taken for a long time it 
acts as a tissue poison and a check upon waste. Epithelial and nerve 
degeneration and fibrous overgrowth follow the first or poisonous irri- 
tative action ; and fatty change the second. In the alcoholic, tremor 
of the hands and tongue is seen. The action of the muscles is un- 
steady. The mind is dull, the temper irritable, forgetfnlness is most 



THE DATA OBTAINED BY OBSERVATION. 215 

common, and later a dementia and epilepsy may ensue. Alcoholic 
neuritis, to be described later, is of frequent occurrence. 

Gastro-intestinal catarrh with poor appetite and constipation is most 
liable to ensue, and later cirrhosis of the liver and kidneys. Endar- 
teritis and cardiac dilatation develop in some independently ; in others 
with the nervous affections, delirium tremens. 

Grain-poisoning. Three forms are seen. When the grain is con- 
taminated by ergot, symptoms known as ergotism occur. Chronic 
ergotism may cause gangrene or a train of nervous symptoms in which 
convulsive movements are most prominent. In the gangrenous form 
the toes and fingers are the seat of mortification. The process is pre- 
ceded by anaesthesia, paresthesia, and pain. In the convulsive form 
there is slight fever with some weakness and tingling sensations in the 
body. Cramps and contractures occur in the extremities, continuing 
for hours or days, and relapsing frequently. A mild delirium or the 
development of melancholia or dementia attends the convulsive form. 

In other intoxications fever is not so pronounced. In lathyrism the 
symptoms are those of spastic paralysis, which may proceed to para- 
plegia. In pellagra, a disturbance due to maize, there are disorders 
of digestion, loss of sleep, general pain, and debility. The digestive 
symptoms are those of salivation, dyspepsia, and diarrhoea. A pecu- 
liar erythema arises. Subsequently, desiccation and desquamation of 
the epidermis occur, and often small boils develop. Headache, back- 
ache, spasms, and paralysis of the legs occur in the severe and chronic 
forms. The nervous symptoms may give Avay to melancholia. 

Lead-poisoning. Intoxication due to lead or plumbism may be 
acute or chronic. In the acute form we have symptoms of gastro-in- 
testinal irritation with constipation and extreme colicky pains. Anae- 
mia may develop rapidly, and pronounced nervous symptoms arise. 
Among the latter we have neuritis, convulsions, epilepsy, and delirium. 
Hemorrhages from mucous membranes may be seen, and a form of 
nephritis develops rapidly. The urine contains albumin and tube-casts. 
Fever is not a pronounced symptom. 

The characteristic symptoms of chronic poisoning are (a) saturnine 
cachexia, in which anaemia is most pronounced ; (6) colic ; (c) paralysis, 
which may be acute, subacute, or chronic, and which usually develops 
without fever. The paralysis may be anti-brachial, causing character- 
istic wrist-drop ; brachial, in which the scapulo-humoral form of paraly- 
sis is seen, and an Aran-Duchenne class, resembling chronic anterior 
poliomyelitis. Another is the peroneal type, in which the lateral 
peroneal muscles, the extensor communis of the toes and the extensor 
proprius of the big toe are paralyzed, causing the steppage gait. Fi- 
nally, paralysis of the adductor muscles of the larynx occurs in lead- 
poisoning. The paralysis often extends from a local group of muscles 
throughout the body, presenting symptoms like those of an ascending 
paralysis with rapid wasting. In other instances the general paralysis 
occurs primarily, the wasting and loss of power going hand in hand. 
Fever sometimes attends a general paralysis in lead-poisoning, (d) The 
cerebral symptoms of the acute form have been mentioned. In the 
chronic cases they may also occur. Optic neuritis, or neuro-retinitis, is 



216 GENERAL DIAGNOSIS. 

common. Delirium, with hallucination, may occur. Tremor is a common 
symptom. It must not be forgotten that headache, convulsions, epi- 
lepsy, and delirium may be manifestations of lead encephalopathy, 
even in cases in which the history of exposure to lead is not direct ; (e) 
chronic lead-poison leads to arterial sclerosis and contracted kidneys with 
hypertrophy of the heart ; (/) gout is very common, and may be seen in 
both acute and chronic forms, particularly in the big toe ; (g) as described 
in the section in which the mouth and gums are discussed, the blue line 
is the specific symptom of lead-poisoning. The reader is referred to 
that chapter for a description of the line. It must be remembered that 
in all forms of obscure nervous disease, in gastro-intestinal irritation, 
in arterio-sclerosis, and gouty arthritis, this line must be looked for. 

Arsenic-poisoning. Acute arsenical poisoning is attended by 
severe symptoms of gastro-intestinal irritation followed by the rapid 
development of collapse. Fever is not a prominent symptom unless 
recovery is about to take place. The temperature is subnormal, but 
as the collapse symptoms disappear fever due to gastro-intestinal ulcer- 
ation develops. 

In chronic arsenical poisoning the fever occurs only if there is great 
irritation of the mucous membranes, as of the conjunctiva, mouth, or 
pharnyx. In this form, in addition to the irritation of these mucous 
membranes, there may be subacute gastro-intestinal catarrh, with diar- 
rhoea. In other instances there is profound anaemia and debility, with 
paresthesia and neuralgia. In others, again, paralysis like that of lead 
palsy may occur. It must not be forgotten that puffiness under the 
eyelids may be due to this cause. 



CHAPTER XVI. 

THE DATA OBTAINED BY OBSERVATION -(Continued). 

Causal relation of bacteria to disease, Koch's laws, value in diagnosis. Bacteria: 
Saprophytes, parasites, pathogenic, non-pathogenic, aerobic, anaerobic, facul- 
tative anaerobic. Morphology : Micrococci, bacilli, spirilla — Micrococci. Mor- 
phology : Form and size. Reproduction, fission ; grouping. Biological char- 
acters : Non-motile. Pigment production. Liquefaction of gelatin. Production 
of acids Toxic ptomaines and toxalbumins — Bacilli. Morphology: Form and 
size. Reproduction, fission, spores ; grouping. Biological characters : Motility. 
Pigment production. Liquefaction of gelatin. Production of acids. Putrefaction, 
fermentation. Spirilla. Morphology : Form and size. Reproduction, fission ; 
grouping. Biological characters. Motility. Pigment-production. Liquefaction 
of gelatin. Production of acids and fermentation wanting. 

FEVER. THE INFECTIONS. 

We have already indicated the diagnostic significance of the type of 
the fever (Chapter XIV.). Following the lead in part of the subjective 
symptoms, we next examine every organ and structure of the body 
when the symptom — -fever — is present. By this examination we will 
find either (1 ) a functional disturbance of some organ of the body ; (2) 
an inflammation ; (3) or we will find a general process, or infection, any 
local inflammation being secondary, brain disease and intoxications 
having been excluded. 

1. Any functional disturbance of one or more organs — glandular — 
attended by fever must be looked upon as an intoxication. Fevers due 
to such causes have been discussed in the preceding chapter, so we 
pass on to inflammations, toxic and infectious, which cause fever. 

2. Suppose we find local inflammation of some part, as an inflamma- 
tion of the nares, a bronchitis, or an apparent gastritis or enteritis. 
The inflammation may be toxic or it may be infectious. As another 
example, let us take the kidneys. Blood, albumin, and renal casts 
would show that they are the seat of inflammation. This inflammation 
may be toxic, as from cantharides, or the toxin of an infection, or it 
may be infectious. In either instance the fever is caused by the local 
process. To determine whether the inflammation is toxic (generally 
catarrhal) or infectious, we must rely upon the data obtained by in- 
quiry, the clinical course, and the result of the examination described 
in Chapter XYIL, which discloses the method of determining the 
presence of an infection. 

3. If the above are excluded we proceed with the bacteriological 
diagnosis. By this means we find if a general infection prevails. Such 
diagnosis may be necessary also to recognize pyaemia and septicaemia. 



218 GENERAL DIAGNOSIS. 

The Infections. 

It had long been surmised that micro-organisms had much to do 
with morbid processes, and that the relationship was that of cause and 
effect. It was known, for instance, that suppuration, surgical fever, 
erysipelas, hospital gangrene, and puerperal fever were associated with 
conditions which favored the multiplication of the lower forms of life. 
"What relationship the micro-organisms bore to the various affections 
was not known. Least of all were the specific micro-organisms which 
were the causes of particular specific morbid processes known. I have 
said that it was surmised ; but there was groping about, a difference of 
opinion, and a maximum of theory, a minimum of fact. It is true 
that in relapsing fever the spirillum had been found, and that none 
had been found in any other disease. Moreover, it is true that mon- 
keys had been inoculated and the disease reproduced in them. It is 
true that the bacillus of anthrax had been seen in the blood in the 
early sixties. It is true that the great genius Pasteur had prosecuted 
studies of bacteria in animal and vegetable pathology to most brilliant 
and practical conclusions. Nevertheless, there were confusion and 
doubt ; scientists were not satisfied with the demonstrations which 
undertook to prove the causal relationship of micro-organisms to 
disease. 

Laws to Establish Causal Relationship. By the genius of Robert 
Koch theories and objections were set at naught. The scientific world 
was fully prepared by the labors of early investigators to accept Koch's 
conclusions. They were based upon an array of well-authenticated 
facts, which anyone could prove for himself. The postulates formu- 
lated by Koch, the fulfilment of which he considered as necessary in 
order to identify an organism as the etiological factor in a given disease, 
are as follows : The constant presence of the organism in the affected 
tissue of the diseased animal ; its isolation from the pathological lesions, 
and its continuous cultivation in pure cultures under artificial condi- 
tions through many generations ; the power of such pure cultures to 
reproduce the disease when inoculated into susceptible animals ; and 
the detection of the organism in pure culture in the lesion found in the 
animal thus inoculated. The experimental circle was then repeated. 
In this manner the causal relationship of micro-organisms to special 
diseases had been proved by the distinguished investigator in the case 
of anthrax, tuberculosis, and other affections. In a certain number of 
cases particular species of bacteria and other micro-organisms have 
been isolated from definite diseases and reasonably believed to stand in 
causal relation to them, but which have, nevertheless, not fulfilled all 
the requirements of the above-cited postulates. The difficulties often 
encountered are : The impossibility of reproduction in animals of the 
clinical and pathological features that the diseases present in human 
beings, as is the case with typhoid fever, influenza, gonorrhoea, and 
fibrinous or lobar pneumonia ; and the impossibility of satisfactorily 
cultivating certain other organisms that are the constant accompani- 
ment of particular diseases of man, as, for instance, the plasmodium 
malaria?, the bacillus of syphilis, and the amoeba coli. 



THE DATA OBTAINED BY OBSERVATION. 219 

The infectious diseases, then, are those that are produced by a living 
contagion or micro-organism. The organism is introduced into the 
body through the skin, if the latter is the seat of some lesion, as in 
syphilis, tuberculosis, and anthrax ; through the air-passages, as in 
diphtheria, scarlet fever, and other specific fevers ; or through the 
digestive tract, as in typhoid fever, dysentery, and cholera. The 
virus, as the living cause is named, in many instances produces certain 
changes at the point of entrance — the initial phenomena. It is then 
conveyed by the lymphatics or bloodvessels to near-by organs in the 
related lymph-stream or blood-stream, or transmitted to the whole 
body. When the whole body is affected an eruption is sometimes pro- 
duced (eruptive fever), or the blood is changed in quality (diphtheria), 
or many tissues are affected simultaneously, or the nervous system is 
notably disturbed. The above are the phenomena of general distribu- 
tion of the virus, or of infectiveness. The virus or poison thus distributed 
may be the living organism, as in tuberculosis or anthrax, or it may be 
a poison generated by the organism, a toxin or ptomaine, as in diphtheria. 

Phenomena of secondary local distribution are due to local changes 
in organs affected secondarily. The poison has a special affinity for 
certain organs, as in whooping-cough, parotitis, pneumonia, or leprosy. 

In some instances the local phenomena are so marked as to give to 
the disease a corresponding distinctive feature. They are the granulo- 
mata. Bearing in mind the above distinctions, specific infectious dis- 
eases are divided into six classes. 

First Class. Acute Specific Fevers. The initial phenomena are 
slight. The phenomena of infectiveness are marked ; an eruption is 
one of the most characteristic. The secondary local phenomena are 
variable. The following are included in this class : Typhoid fever, 
typhus fever, variola, varicella, scarlet fever, measles, relapsing fever, 
rubella, influenza, dengue, the plague, and cholera. 

Second Class. Specific Inflammation. Initial phenomena indefi- 
nite. General phenomena (infectiveness) variable, but no eruption. 
Specific affinity of poison for one particular structure. Whooping- 
cough, mumps, diphtheria, dysentery, erysipelas, tetanus, hydrophobia, 
cerebro-spinal meningitis, rheumatic fever, and pneumonia belong to 
this class. 

Third Class. Contagious or Infectious Suppuration. Initial phe- 
nomena marked (suppuration) ; generalization not marked unless the 
virus enters the blood ; secondary local phenomena decisive. Gonor- 
rhoea is one type, pysemia, or any infection from pus-producing micro- 
organisms, as abscess, carbuncle, etc., a second, in which the blood is 
infected. 

Fourth Class. Infective Granulomata. Distinct initial phenom- 
ena. Phenomena of generalization not marked, or like specific fevers. 
Secondary local phenomena prominent. Examples : Tuberculosis, 
syphilis, leprosy, and glanders. 

Fifth Class. Iliasmatic Diseases. No initial phenomena. 

Sixth Class. Vegetable Parasitic Diseases. 

It is readily seen that when the definite cause of an infectious disease 
is isolated, and the morphological and biological properties of the 



220 GENERAL DIAGNOSIS. 

causal micro-organism determined, the clinician has acquired a valu- 
able aid to diagnosis. Indeed, in such affections the bacteriological 
diagnosis has become an absolute certainty. 

Bacteria. 

To determine the micro-organism which causes the infection the 
student must be familiar with the morphology and biological properties 
of the various forms of bacteria. (By means of this knowledge a bac- 
teriological diagnosis is made.) The morphology : The shape, the size, 
the mode of reproduction and grouping are to be studied. Bacteria or 
fungi are divided morphologically into micrococci or spherical bacteria, 
bacilli or rod-shaped bacteria, and spirilla or twisted forms. Bacteria 
procreate by simple fission, and are therefore known as fission-fungi or 
schizomycetes. Some forms also produce spores. The biological proper- 
ties include motility, color, the growth on various culture-media and 
under various temperatures, and the product of vital activity. 

Micrococci. 

Morphology. To this group belong the spherical bacteria. Each 
coccus is of nearly equal diameter in all directions. They vary in size 
from 0.1 /i to 1 or 2/i. A micromillimetre (/i) is one twenty-five thou- 
sandths of an inch. The various micrococci resemble each other so 
much in form and size that they cannot be distinguished by their micro- 
scopic appearances. To distinguish them we depend on the color and 
character of their growth in various culture-media, on their pathogenic 
power, and on other biological differences. The mode of grouping, 
after fission or reproduction, is an important characteristic by which 
varieties are differentiated. Just before dividing they are not perfectly 
spherical, but short or long, oval. After division (for they divide in- 
definitely when growing) the staphylococci are solitary or in pairs, or, 
occasionally, in groups of four or in clusters, roughly likened to a 
bunch of grapes, from which latter grouping they derive their name. 
The organism is called a diplococcus when associated in pairs. Some- 
times two or four are included in a capsule. Zoogloea are groups of 
cocci held together by a transparent glutinous substance. Streptococci 
are characterized by a grouping in chains, known as chaplets or torula 
chains, because division takes place in one direction only. When 
division takes place in two directions, groups of fours, or tetrads, are 
formed ; and when in three directions, groups or packets of eight are 
formed, of which the sarcince are the most familiar examples. These 
names, significant of the grouping, refer to the predominating groups 
as seen in microscopic preparations. In some of such groups, for in- 
stance, are seen only diplococci or streptococci ; but in all, transitional, 
irregular, and 'accidental groupings may be observed. 

Biological Characteristics. Micrococci are not motile and do not 
form spores. Products of vital activity : The various forms of bacteria 
are also distinguished by noting the difference in the products of vital 
activity. Of these, pigment-production is one of the most apparent. 
The staphylococcus pyogenes aureus and citreus are chromogenic or pig- 



PLATE 



Fig 2. 







\ 













.-1. Tubercle-bacilli. 



ft. Pneumococcus. 



A. Anthrax. R. Streptococcus and Staphylococcus. 

Fiy. 4. 







,4. Comma-bacillus. /?. Gonococcus. 

Fi v 



A. Recurrent Spirilla. /?. Leprosy. 
Fig. 6. 




/4. Normal Blood. B. Normal Blood. 



A. I,euk:emia. /?. Eberth's B 



THE DATA OBTAINED BY OBSERVATION. 221 

ment-producing bacteria. The liquefaction of gelatin, when cultures 
are made, is a biological characteristic which assists in the diagnosis of 
the various species. Some pathogenic as well as non-pathogenic germs 
have this effect on the nutrient medium ; others of both classes do not 
affect it. A peptonizing ferment is formed during the growth of cells 
which acts upon and dissolves the gelatin. The amount, degree, and 
character of the liquefaction serve to distinguish various species. The 
staphylococcus pyogenes aureus and albus (as well as some others) are 
liquefying micrococci. Production of acids: Many bacteria produce 
an acid — lactic acid, acetic acid, butyric acid — which gives an acid 
reaction to the culture-media. This may be seen if a neutral litmus 
solution has been added to the gelatin. The pink color produced indi- 
cates the presence of an acid. Culture-media, it must be remembered, 
are alkaline or neutral. The pathogenic micrococci which produce an 
acid are the staphylococci of pus — lactic acid. 

Putrefactive fermentation is set up by bacilli and not by micrococci. 
Other products of vital activity need not concern us, as they are pro- 
duced by non-pathogenic forms. 

Toxic ptomaines and toxalbumins are products of many forms of patho- 
genic bacteria, and cause the symptoms of infective diseases in many 
instances ; thus in diphtheria the local infective inflammation represents 
the seat of activity of the bacillus, the point at which its poisons are 
being manufactured at the expense of the tissues in and on which it is 
growing ; the general symptoms are due to the toxalbumin that has 
been absorbed by the circulating fluids from this local seat of action. 
The isolation and detection of the toxalbumins are not sufficiently easy 
to warrant such a mode of investigation for diagnostic purposes. Often 
the results of inoculation, by which the lethal effect is produced, aid in 
the diagnosis of the suspected ailment. (See Plate III., Fig. 2, b.) 

The Bacilli. 

Morphology. The bacilli, or rod-shaped bacteria, differ widely in 
form, in size, and in modes of grouping after fission. Form and size : 
The longitudinal diameter is greater than the transverse, and the 
forms vary from short oval or slender rods to long filaments ; some- 
times short rods and long filaments are seen in pure cultures of the 
same bacillus, as in the typhoid bacillus. The transverse diameter of 
a given species does not vary, as a rule. The form of the extremities 
of the rods must be observed. They may be square, slightly rounded, 
round, oval, or lance-shaped or spindle-shaped. Reproduction and 
grouping: Fission or reproduction takes place by binary division, 
transverse to the longitudinal axis. They group in long chains, or are 
solitary or united in pairs. They may be surrounded by a capsule or 
collect in zoogloea masses. 

Spores. When conditions unfavorable to continuous multiplication 
by transverse division arise certain bacilli possess the property of 
entering into a permanent or resting stage. In this case there de- 
velops within the body of the bacillus an oval, egg-shaped structure — 
an endogenous spore. The spore represents the inactive stage, and lies 



222 GENERAL DIAGNOSIS. 

dormant until circumstances favorable to growth reappear, when it 
develops into a bacillus identical with that from which it was formed. 
Spores do not develop into spores but into bacilli. The spores retain 
their vitality for months or years, and resist desiccation. They are 
spherical or oval, and highly reproductive. They are formed by con- 
densation of protoplasm at the centre or at one end of the bacillus, 
where they are retained in a linear position until set free. Some 
bacilli grow into long filaments during spore-formation ; others change 
their shape, swelling at the centre, becoming spindle-shaped or club- 
shaped, according to the location of the spore within it. Many bacilli 
do not change their shape at this stage. The spores are free or col- 
lected in masses with the bacilli as well as located in the parent bacillus. 

Motility. The bacilli are often actively motile, because of the 
presence of flagella. The movement is one of progression in different 
directions. It may be slow and deliberate, in a to-and-fro motion, or 
serpentine, or a quick, darting forward motion. 

Biological Characters. Products of vital activity. They may be 
ascertained in the same manner as in the study of micrococci. Pig- 
ment-production is seen in cultures of the bacillus pyocyaneus or bacil- 
lus of green pus, of which there are several varieties producing various 
shades of blue or fluorescent green. Liquefaction of gelatin : This is 
produced by the bacillus anthracis and the bacillus pyocyaneus, the 
" comma " bacillus of cholera and many other species. Production of 
acids : The bacillus coli communis produces lactic acid. Fermentation : 
The latter bacillus sets up fermentation of carbohydrates, as of glucose, 
lactose, and saccharose. (See Plate III.) 

The Spirilla. 

Morphology. They are seen in the form of curved rods or spiral 
filaments. The shorter ones are curved, the longer are spiral, like a 
corkscrew. The curved filaments may be short and rigid, or long and 
flexible. 

Reproduction. They reproduce by binary division (fission). 

Biological Characters. Motility. " They' are motile; the move- 
ment is rotary, as well as progressive in the direction of the long axis 
of the filament. The presence of flagella is determined by Loffler's 
method of staining. They are single at the ends of rods, or several 
are seen at one extremity, or one or more may occur at both ends. 
Pigment-production: Pathogenic spirilla do not produce pigment. 
Liquefaction of gelatin: The spirillum of cholera Asiatica (comma 
bacillus) and the spirillum of cholera nostras (Finkler and Prior) both 
liquefy gelatin in a peculiar manner. (See Plate III., Fig. 4, a.) 



CHAPTER XVII. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 

Data obtained by inquiry — By observation. Local infection — General infection. 
Pyaemia ; septicaemia. Terminal infections. Fever in carcinoma. Afebrile 
infections. Infections of certain bacteriology; of uncertain bacteriology. Bac- 
teriological diagnosis. Method of research : Microscopical examination, culti- 
vation, inoculation. Essentials in technique. — Method of research : Blood, dis- 
charges, exudations ; mode of collection. Apparatus. Preparation of apparatus. 
Sterilization. Microscopical examination : Technique, cover-glass preparations. 
Methods of staining ; spores. "Hanging drop" — Cultivation of micro-organ- 
isms. Culture-media. Tube- and plate cultures. Smear- and stab-cultures — 
Inoculation of animals — Special bacteriological diagnosis. 

FEVER. THE INFECTIONS. 

Unfoktunately, the cause of many of the infectious diseases has 
not been definitely isolated. This group is largely the infectious 
disorders which are epidemic and contagious. In order to diagnosti- 
cate them it is necessary to associate with the mode of onset and clini- 
cal course of the disease the facts and laws pertaining to epidemics and 
to contagion. Data, therefore, obtained by inquiry are quite necessary 
to establish the diagnosis. Such data are useful in confirming the 
results of an objective or bacteriological examination of the patient, 
even though the diagnosis be at once established by the latter method. 

Data Obtained by Inquiry. In the first place, we note the social 
history, learning this while preparing for the objective examination. 
It should be personal and general. The age, the sex, the habits, the 
occupation, are looked into. The nature of the prevailing diseases in 
the community are known or sought for, and all possible unusual cir- 
cumstances in food, drink, clothing, are inquired for. In short, a his- 
tory of exposure to influences which attend an intoxication or those 
which permit infection are to be zealously sought for. 

An inquiry for previous diseases does not imply a history alone of a 
previous infectious disease, but a history of such diseases as are often 
followed by infection. Thus, a history of a previous attack of gall- 
stones or of renal calculus may be a clue to the localization of an infec- 
tious process. Too much stress cannot be laid upon the diagnostic 
value of the data obtained in this manner. 

The next data obtained by inquiry is the history of the present dis- 
ease. The mode of onset is of itself suggestive. Sudden onset points 
more closely to an intoxication, though not necessarily, although more 
likely in children. Otherwise sudden onset usually indicates one of 
the short infections, of which scarlatina and pneumonia are representa- 



224 GENERAL DIAGNOSIS. 

tive types ; while gradual onset, a long infection, of which typhoid 
fever is a type. 

The subjective symptoms are then inquired for and their site affords 
a clue as to the steps to be taken in the objective examination. Thus, 
pain in the throat with difficulty in swallowing calls for an examination 
of the fauces ; pain in the chest, of the lungs ; in the prsecordia, of the 
heart, etc. Any functional disturbance of an organ should also lead us 
to a study of it. 

Data Obtained by Observation. The appearance of the inflam- 
matory process may be sufficient to decide its nature, however — a boil, 
an abscess, a carbuncle, which gives rise to more or less fever, because 
they are local infections, are readily recognized. 

Local Infection. When not preceded or accompanied by any pro- 
cess elsewhere the infection is said to be local. An appendicitis, a 
cholangitis, an inflammation of a serous membrane, as well as a boil or 
carbuncle, may be a local infection. In like manner the accidental 
wound of a surgeon by which he is inoculated or infected by the micro- 
organism of the pus may be an infection. The natural or acquired 
wounds of the puerperium may also be infections. A local infection 
here arises. It must be borne in mind that any local inflammation may 
be infectious. It is not our purpose to consider here local infections. 
Some, indeed nearly all, of the streptococcus and staphylococcus infec- 
tions are local. The general symptoms are produced by a toxemia, 
the toxin alone passing into the blood. 

General or Systemic Infections. General infections alone, and 
those which may have more pronounced local expression, as pneu- 
monia or the pneumococcus infection, are discussed. It is of importance, 
however, to remember that in determining whether a local inflamma- 
tion is infectious or not, we use the same methods that are employed to 
determine the nature of a general infection. 

It is also important to remember that a local infection may be circum- 
scribed and cause a toxic fever. On the other hand, a small portion of 
the purulent exudate from the infection may get into the circulation 
and be carried to distant parts, as the brain, the lungs, the kidney, the 
joints, the spleen. Distant foci of inflammation are set up, giving rise 
to multiple small abscesses in the organs affected. Pycemia is the name 
of this form of systemic infection. Finally, such local infection may 
become general and the case terminate in septicemia. 

Pyaemia is characterized by rigors, fever, usually intermittent, and 
sweats. There is exhaustion ; the skin is slightly icterode. The odor 
of the breath is sweet. There is anorexia, nausea, perhaps vomiting, 
frequently diarrhoea. Erythematous eruptions are seen. With these 
general symptoms there are present the physical signs of abscess in the 
lungs or the spleen or other organs of the body, or we may have an 
endocarditis. When the affection is limited to the portal area, and 
multiple abscesses of the liver succeed a purulent process in the area 
of the portal vein, the general symptoms are combined with enlarge- 
ment of the liver, which is tender and painful, and perhaps with deeper 
jaundice. The micro-organisms which invade the system and cause 
areas of suppuration are the streptococcus and staphylococcus pyo- 



THE DATA OBTAINED BY OBSERVATION. 225 

» 

genes, the micrococcus lanceolatus, the gonococcus, the bacillus coli 
communis, the bacillus typhi abdominalis, the bacillus proteus, the 
bacillus pyocyaneus, the bacillus influenzae, and the bacillus aerogenes 
capsulatus. 

Diagnosis. Pyaemia resembles in many respects tuberculosis of the 
kidneys and calculous pyelitis, in both of which recurring rigors and 
sweats are common. In gross aspects it resembles malaria. (See Inter- 
mittent Fever.) In prolonged cases of pyaemia the symptoms may 
resemble typhoid fever, but leukocytosis is present in the former con- 
dition. Ulcerative endocarditis and acute miliary tuberculosis usually 
resemble septicaemia, but may be confounded with pyaemia. Any febrile 
process associated with chills may be taken for pyaemia. These phe- 
nomena are seen in grave anaemias, in Hodgkin's disease, in hepatic 
intermittent fever, and in the intermittent fever of carcinomatosis. 
(See Chills, Chapter XIV.) Post-febrile arthritis, after scarlet fever 
and gonorrhoea, is in all probability pyaemic. Of course, we rely in the 
diagnosis of pyaemia upon the data obtained by bacteriological methods 
when their employment is practical. 

Septicaemia. Again, we may find with the above-described wound, or 
without any apparent local inflammation, fever, which is more or less 
continuous. In addition there may be an occasional rigor. The pulse 
is rapid, exhaustion, anaemia, and some emaciation are present. Sec- 
ondary infection of other structures may or may not be present. 
Microbic infection of the blood usually takes place. The process is a 
septicemia. If it originates from a local infection it is known as pro- 
gressive septicemia. If independently of any apparent local infection 
it is a cryptogenetic septicaemia. The former is easily recognized, par- 
ticularly if there is a history of a primary local infectious process. 
The micro-organisms which may give rise to the latter are the staphy- 
lococcus pyogenes, the streptococcus pyogenes, the bacillus proteus, the 
bacillus pyocyaneus, and the micrococcus lanceolatus. It is recognized 
by a bacteriological diagnosis. 

The accompanying chart (Fig. 42) represents the course of an infec 
tion and various areas of secondary infection in a general septicaemia. 
The illness extended over a period of thirty-five days. The first five 
days, as indicated by the chart, there was pneumonia at the base of the 
left lung. The crisis only is represented. From the tenth to the 
twenty-first day, to save space, the chart does not give the tempera- 
ture range. During this time the fever was continuous. On the 
twelfth the right pleura was infected ; on the nineteenth the fem- 
oral vein of the right leg, the temperature not rising above 101°. On 
the twenty-first, as the chart indicates, a patch of pneumonia was found 
in the right lung posteriorly. On the twenty-fourth pseudocrisis, and 
on the twenty-fifth and twenty-sixth the true crisis took place. On 
the twenty-ninth and thirtieth there was reinfection of the pleura of 
the left side. On April 3d phlebitis of the femoral vein of the left leg 
developed. During the course of the disease there was a low-pitched 
endocardial murmur, which in all probability was anaemic. Sweats, 
attacks of collapse, and irregular rigors took place. Life was imperiled 
at the time of the collapse. The spleen was enlarged ; the sputa con- 

15 



226 



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227 



tained pneumococci. The blood examination was negative. The 
patient recovered. 

Fever, varying in type, sweats, emaciation, anaemia, and exhaustion 
are the common general symptoms. The pulse is increased in f re- 
queue v, and is dicrotic and compressible. The heart sounds grow 
weak,* the breathing hurried. There is slight delirium at times. The 
urine contains albumin and casts. It is scanty, high colored, and of 
high specific gravity. In some forms there is leucocytosis. There is 
anorexia, nausea, and vomiting, often diarrhoea. As the case advances 
the symptoms of the typhoid state develop. (See Chapter XIV.) 

Objective Sigxs of Septicaemia. In other instances there is 
marked evidence of a septic process in the structures which carried the 
poisoned or infected blood from the primary point of entrance of the 
infecting material — the infection atrium. Hence in this infectious pro- 



Fig. 43. 



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cess — in septicaemia — we may see lymphangitis and adenitis. The 
spleen is enlarged. There may be phlebitis, especially of the femoral, 
inflammation of which is always infectious in character. Other veins 
may be affected. The endocardium is infected, and indeed endocarditis 
may be the chief symptom-complex of the septic process. The serous 
membranes may be involved, so that septic pleurisy or meningitis or 
pericarditis or jieritonitis or arthritis, singly or combined, may be local 
expressions of the sepsis. Hemorrhages from the mucous membranes, 
or subcutaneously, either because the blood is destroyed (toxic) or be- 
cause of multiple small infarcts, frequently attend septicaemia. Hemor- 
rhages may be the most pronounced symptom of certain forms of in- 
fection, as that due to capsulated bacilli. A slight jaundice of toxic 
origin may prevail. 

Toxic Symptoms. In some instances there is a profound toxcemia in- 
dicated by delirium, stupor, and later coma and convulsions. The 



228 GENERAL DIAGNOSIS. 

typhoid state may predominate. The intoxication may overwhelm 
the cardio- vascular centres. The pulse grows rapid and feeble, the 
respirations hurried and shallow. The urine is diminished in amount 
and contains albumin. 

The clinical course varies with the infective agent. Streptococcus 
infections are characterized by chills, high fever, and an extreme septic 
state. Infection by the capsulated bacilli (Howard) gives rise to a 
hemorrhagic septicaemia. In other infections the greater part of the 
clinical course may be afebrile. Toxic symptoms, and especially in- 
creased frequency of pulse-rate with collapse phenomena, are present, 
as in forms of infectious peritonitis. 

A general infection, or this general expression of septicaemia, occurs 
in the course of diseases in which the clinical course of the infectious 
process is usually a definite one. Hence we speak of typhoid septi- 
caemia or a pneumococcus septicaemia when the intoxication or general 
infection is paramount to the local process. Then in tuberculosis and 
other prolonged infections septicaemic symptoms arise, so that the ter- 
minal phenomena of the disease are usually due to a mixed infection. 
It must then be understood that pyaemia or septicemia or septico- 
pyaemia are not due to special micro-organisms in the sense that 
typhoid fever is due to the bacillus typhosus, malaria to the Plasmo- 
dium, or pneumonia to the pneumococcus. 

Terminal Infections. At the termination of many chronic diseases, 
as the various fibroid affections — cirrhosis of the liver, the kidneys, 
endarteritis, or spinal cord disease, and in carcinoma — there is fever. 
This is generally due to an infection which the weakly resisting organ- 
ism invited. 

Flexner has studied the terminal infections. In 255 cases of renal 
and cardiac disease he found 213 infections, excluding tuberculosis. 
They were local and general. Infections of the serous membranes are 
the most common. The old clinical fact that serous inflammations 
were complications of Bright' s disease has been proven by bacteriologi- 
cal methods to be due to an infection, and not as formerly thought to a 
chemical change in the blood. The following micro-organisms are met 
with : the streptococcus pyogenes, the pneumococcus, the staphylococ- 
cus aureus, the bacillus proteus, the gonococcus, the bacillus pyocy- 
aneus, and the gas bacillus. 

Tuberculous infection is also a terminal process in many diseases. 
Frequently an acute tuberculosis of serous membranes is found in the 
course of chronic heart or kidney disease. 

Fever in Carcinoma Fever occurs in the course of carcinoma 
under two circumstances. If it is proven that carcinoma is an infec- 
tion this process is one cause of the fever. It is well known, however, 
that in rapidly growing cancer of the liver, fever, often intermitting in 
type, is present. It may also be present in general carcinoma, and in 
all probability in carcinoma of the lungs and of the bones. But fever 
in the course of cancer may be due to a secondary infection. It can be 
readily understood that the process is likely to take place if the malig- 
nant disease occurs in the course of any of the tubes or channels. The 
infection atrium is the inflammation or ulceration found so often in 



THE DATA OBTAINED BY OBSERVATION. 229 

carcinoma, and in consequence local suppuration occurs. From this 
local infection a general septicaemia may arise. 

Afebrile Infection. Although most infections cause such' reaction 
of the system as to produce fever, some few are afebrile. Such is the 
case with tuberculosis — when it is local — and of syphilis in certain 
stages. The writer is of the belief that when the syphilitic poison is 
active — i. e., productive of lesions — fever is present some time during the 
twenty-four hours. He is fully persuaded that mistakes are made 
because fever is not considered a part of the syphilitic infection. He 
has seen it in all of the arbitrarily called stages of infection, and pre- 
senting all types of fever — intermittent, remittent, and continuous. 
The rise may be moderate or very pronounced. For its detection the 
thermometer should be employed every two hours. 

Typhoid fever is an example of an infection which sometimes runs 
its course without rise in temperature. This is very rare, but never- 
theless does at times occur. 

Infections of Certain Bacteriology. In our investigation of the 
cause of the fever in a suspected case we have found evidence of an 
infection as shown by (1) the phenomena of a local inflammation, (2) 
by the presence of pyaemia or (3) of septicaemia. The clinical course 
alone enables one to make a diagnosis generally. At times we may 
have to resort to more positive methods. The nature of the process, 
however, is usually proven ; the nature of the infection must be decided 
by bacteriological examination. We must, therefore, follow this mode 
of recognition of an infection. 

Infections of Uncertain Bacteriology. The presence of those 
infections, the bacterial cause of which is not known, must be deter- 
mined somewhat differently. In one group we must be content with 
the data obtained by inquiry and by observation, comparing the symp- 
toms with the known course of a similar disease. Scarlet fever can 
only be recognized in this way. In subsequent chapters, therefore, the 
infections are divided into those recognized by inquiry and observation, 
and those recognized by supplementary observation with bacteriological 
methods. 

The classification of the infectious diseases is based upon the fact 
that a specific micro-organism is known which gives rise to phenomena 
similar in the respective infections. In other words, the infection of 
malaria or of tuberculosis or of diphtheria follows a recognized clinical 
course. The period of invasion, the mode of onset, the symptoms 
throughout the course of the disease, are with notable exceptions prac- 
tically the same. 

Bacteriological Diagnosis. 

Bacteriological examination includes (1) the finding of the specific 
micro-organism in the blood or tissues (of the subject) or in the patho- 
logical secretions or excretions ; (2) the isolation and cultivation of the 
micro-organism ; (3) the inoculation and the reproduction thereby of 
the disease in animals. In many infections the morphological pecu- 
liarities of the micro-organism are so characteristic that a diagnosis may 
be established by finding it in the blood or the secretions. Thus an 



230 GENERAL DIAGNOSIS. 

examination of the blood, with or without staining, will disclose the 
presence of the micro-organism of relapsing fever and of anthrax and 
the protozoa of malaria. The examination of inflammatory products 
of an infection, as the sputa in pneumonia or tuberculosis, are sufficient 
to determine the nature of the infectious inflammation of the lungs. 
On the other hand, in some infections, the absence, or rather failure of 
detection, of the micro-organism in the fluids or discharges is not proof 
that the disease is not present in the suspected individual. The infec- 
tion tuberculosis well illustrates the propositions in the last two sen- 
tences. If the bacillus is found in the sputum of a suspected case the 
diagnosis is established definitely, and no further procedures for diag- 
nostic purposes are necessary. In other clinical forms, as tuberculous 
pleurisy, or empyema, or glandular or joint tuberculosis, the micro- 
organisms are few and difficult to find. Cultures, or, more conclusive 
still, inoculations, must frequently be resorted to before a final conclu- 
sion can be arrived at. It is possible that spores alone exist — morpho- 
logical elements difficult to detect by staining and microscopical 
methods, but which may rapidly multiply under favorable culture 
conditions or inoculation conditions. Again, micro-organisms have 
been found in certain infections, and although thus far their causal 
relationship to them has not been fully proved, nevertheless their con- 
stant occurrence in the special affection, and in it alone, renders their 
presence of high diagnostic value. Thus the amoeba of dysentery and 
the plasmodium malaria? of Laveran are diagnostic of their respective 
affections. 

For diagnostic purposes bacteriological investigations must be con- 
ducted in accordance with the methods of bacteriology. Such researches 
are possible at this time, because of (1) the high degree of development 
and mode of use of optical apparatus, including oil-immersion lenses, 
Abbe's condenser and diaphragms ; (2) the discoveries by Weigert of 
the effects of aniline dyes on protoplasm, and the property of micro- 
organisms of taking different stainings ; (3) of the principles of steril- 
ization by heat, by which foreign micro-organisms are excluded ; (4) 
of the use of solid culture-media, and the plate-method of obtaining 
pure cultures suggested by Koch. 

Method of Procedure. 

To determine the presence of moist infections it is necessary to pro- 
ceed as follows : 

A. Examination of the blood. 

B. Examination of the pathological secretions and excretions. 

C. Examination of products of infectious inflammation secured by 
exploratory puncture or evacuation of abscesses. (See Chapter XXI.) 

D. Inoculations of animals with pure cultures of the organism or with 
the products of inflammation, as cheesy matter from a tuberculous abscess. 

E. The use of products of bacterial growth to secure reaction, as 
tuberculin in tuberculosis, and mallein in glanders. (See Tuberculosis.) 

When there is no distinctive pathological fluid all the fluids of the 
body must be examined. In other cases the pathological discharge 



THE DATA OBTAINED BY OBSERVATION. 231 

(pus), or perhaps the diseased tissue, must be studied. We get a 
clue to the direction which the examination is to take from the nature 
of the symptoms. In cases of pulmonary disease, the sputum ; of 
faucial disease, the membrane, pus, or other secretions from the fauces ; 
in intestinal disease, the discharge from the bowels ; and in genito- 
urinary disease, the urine. It must not be forgotten that in many, 
even highly fatal diseases, the blood is not invaded by micro-organ- 
isms. Death is due to the development of toxic substances. Hence, 
as in cholera and diphtheria, the presence of the micro-organism is not 
sought for in the blood, but in the specific excretion or exudation. 
(See Tuberculosis.) 

The Apparatus. The apparatus necessary for the simplest bacte- 
riological research comprises the following : Sterilizers, incubators, 
glass flasks, covered dishes, test-tubes and plates, platinum needles 
fixed in glass handles, raw cotton, materials for culture-media, micro- 
scope, with slides and cover-glasses, and, in addition to lenses of lower 
powers, a one-twelfth oil-immersion lens, and finally the various stains 
used. 

Preparation of Apparatus. Boil all glassware for half an hour 
in a solution of common soda (2 to 3 per cent.), then scrub thoroughly ; 
rinse in warm solution of HC1 (1 per cent.) and then in pure water ; 
drain with tops down ; plug tubes and flasks with raw cotton, fitting 
firmly and evenly, so that the cotton can hold the weight of the test- 
tube ; sterilize in dry oven. The test-tubes (plugged) are placed in a 
rack for further use. 

The tubes and flasks are best filled with the culture-media through 
a spherical funnel that can be plugged with cotton. Then they are 
to be sterilized in the steam sterilizer, as heretofore described. 

The cover-glasses must be thoroughly cleansed by immersion in 
strong nitric acid for a few hours, then rinsed in water, then in alcohol 
and ether. They are then kept in alcohol. 

Sterilization. It should be understood that the first requisite for 
the prosecution of these studies is to secure absolute cleanliness and to 
prevent the invasion of extraneous micro-organisms. The first step is 
thorough sterilization of all appliances required for work and of all the 
media, to destroy previously existing bacteria. 

The sterilization is best accomplished with steam, where the objects 
to be sterilized admit of it. With dry heat a temperature of at least 
150° C. must be applied for at least an hour, and, of course, can only 
be used for glassware and metal instruments. All media (see page 
159), whether solid or fluid, are sterilized by steam. Media which 
cannot withstand long exposure to the necessary heat are sterilized by 
the intermittent application of steam. The reason that this is effective 
is that fully developed bacteria are destroyed at a much lower temper- 
ature and with shorter exposure than are the spores. One application 
kills the developed bacteria, then the material is kept for a time in an 
incubator ; spores develop into bacteria and are easily killed by a 
second application. By repeating this process from three to five times 
the substance is effectually sterilized. If the exposure is made longer 
a much lower degree of heat may be used, so that in the case of blood 



232 GENERAL DIAGNOSIS. 

serum it may be sterilized without coagulating the albumin. Usually 
an exposure of fifteen minutes to steam on each of three successive 
days is used for stable media, and an exposure of an hour on six suc- 
cessive days to a temperature of 70° C. for more delicate media, as 
blood serum. In the intervals the material must be kept at a temper- 
ature of 25° to 30° C. A single application of steam under one to 
one and one-half atmosphere pressure is now often used. 

The ordinary "Arnold steam sterilizer" is as good as any. The 
dry sterilizer is merely a metal box with copper bottom and ventilating 
holes. It is well to have an asbestos casing. 

Metallic articles, as forceps, platinum probes, etc., are best sterilized 
in the flame of a Bunsen burner. 

Collection of Material. A definite, careful method must be ob- 
served when the pathological product is removed from the patient or 
collected for investigation. (See Chapter V., Exploratory Puncture.) 
Pus and fluids should be placed in sterilized glass bottles or tubes, care 
having been taken that instruments for the removal of the fluid were 
previously sterilized. Exposure to air should be as brief as possible. 
The fluid should not be contaminated with blood or antiseptic fluids 
used for flushing or other surgical procedure. If an abscess is opened 
or purulent peritonitis cut down upon, for instance, tube-inoculations 
can be made at the bedside. The previously sterilized platinum point 
should be kept before use in a test-tube closed with sterilized cotton. 
It is dipped into the pus before it flows over the skin, and the pus 
should be free from the blood of the incision. It is at once transferred 
to the medium in the test-tube. Sputum should be collected in a pre- 
viously sterilized bottle, or one thoroughly cleansed by boiling. The 
bottle should have a wide mouth. Care must be taken to secure 
sputum from the lungs, and not the secretion from the mouth and 
fauces. Purulent portions, rather than mucoid, are to be sent for ex- 
amination. Intestinal discharges may be collected in sterilized glass 
jars and examined as soon as practicable. It may be necessary to keep 
the discharge at the temperature of the body. (See Faeces — amoeba 
dysenterica.) 

Examination of Blood. 

To secure blood for microscopical study the finger must be thor- 
oughly cleansed with alcohol and puncture made with a sterilized 
lancet or needle. After the blood flows a few seconds it is removed 
and the cover-slip, previously cleansed in nitric acid solution, is gently 
pressed upon the second overflow. Another cover is placed over the 
blood-stained surface of the first slip, the two rubbed together and 
separated by sliding them apart. (See Fig. 45.) Sternberg prefers to 
spread the blood, which was collected at the edge of the cover- 
slip, by drawing a polished glass slide, held at an acute angle, over the 
cover-slip. In either case this thin film of blood is allowed to dry, 
and can be examined later. Sternberg mounts the blood on a glass 
slide at once. 

1. Microscopical examination is made of the fresh blood. 2. Smear 
preparations on cover-glass or slide are made for staining. 3. A drop 



THE DATA OBTAINED BY OBSERVATION. 



233 



of the blood is examined to observe the biological properties known 
as agglutination, or the Widal reaction — the serum diagnosis. 4. The 
number of white corpuscles is counted, to show the presence or ab- 



FiG. 44. 



F:G. 45. 





Proper method of holding a cover-glass. (Cabot.) 



Illustrating the position of cover- 
glass during the spreading of hlood 
films. (Cabot.) 



sence of leucocytosis (see Blood), and a differential count of these cor- 
puscles is also made. 5. The fresh blood is inoculated on media for 
cultures. 

I. Fresh blood is examined with the oil-immersion objective and 
the diaphragm of the sub-stage condensing apparatus (Abbe's) nearly 
closed. The protozoa? of malaria, the bacillus of anthrax, and the 
spirillum of relapsing fever may be detected. 

II. Cover-glass preparations are examined with the diaphragm open. 
The micro-organisms above mentioned and those of yellow fever and 
typhoid fever may be found in this manner. The method of staining 
the blood is described below. The following solutions are used : 1. 
Basic aniline dyes. 2. Loffler's alkaline methyl-blue. 3. Gram's. 

III. Sebum Diagnosis. The phenomena of agglutination consists 
in the gradual approximation, clumping, and loss of motility in the 
micro-organisms of some infectious disease when the blood of a patient 
suffering from that disease is brought in contact with it. This is known 
as the serum, or Widal reaction, and by means of it a number of infec- 
tious diseases can now be recognized. If a drop of bouillon culture is 
examined with a high-power lens the organisms are seen darting about 
and across the field with great rapidity in various directions. If to 
ten drops of a pure culture of certain varieties of infectious micro- 
organisms one drop of the blood of a patient suffering from that infec- 
tion be added the motility of the organisms is checked and clumps 
appear in the field. The clumps enlarge rapidly, so as to be easily 
visible under a magnifying power of 500 diameters. 

Serum from patients suffering from other diseases or from healthy 
patients does not produce agglutination if the proportion of serum to 
culture in the mixture is 1 to 10 or less. The reaction is specific. 
Thus typhoid bacilli are not clumped by any serum other than that of 
a typhoid patient or a patient immunized against typhoid fever by a 
more or less recent attack of the disease. Typhoid serum clumps no 



234 



GENERAL DIAGNOSIS. 



organism except the typhoid bacillus when used with a certain degree 
of dilution and examined within a certain period of time. 



Fig. 46. 




Bouillon culture of typhoid bacilli before the addition of diluted typhoid serum. 
(Magnified 500 diameters.) After Cabot— serum diagnosis. 

Serum diagnosis has become a valuable mode of recognition of 
typhoid fever, Malta fever, yellow fever, and glanders. It may be of 
use in other infections, as cholera and the pneumococcus infections. 
They are more accurately diagnosticated by other bacteriological meth- 
ods, however, and need not be considered here. 

Method. Three methods of securing the serum reaction are em- 
ployed : microscopic, or quick test of the fluid serum or blood ; the 
microscopic, or quick test of the dried blood ; and the macroscopic, or 
slow test. Each of these methods is of value. The observer should 
select one and make it his object to become thoroughly familiar with 
that selected. 

First, the quick test with fluid serum. The steps are : first, to collect 
the blood ; second, to add it in certain proportion to the fluid culture ; 
third, to examine the slide and cover-slip. 

1. Collecting the Blood. The blood is secured by puncture as 
in the method described in diseases of the blood. If the ear is selected 
it can be bled freely or blood squeezed out by the milking process until 
about fifteen drops are collected in a small test-tube. It is not neces- 
sary to observe strict antiseptic precautions as in other instances. The 



THE DATA OBTAINED BY OBSERVATION. 



235 



instruments and test-tube should be thoroughly cleansed. The blood 
thus collected is allowed to coagulate in the tube, which may occupy 
several hours. It is to be remembered that the clot collects on the 



Fig. 47. 




The same, five minutes after the addition of typhoid serum (dilution 1 : 10), showing 
typical clump reaction. (Magnified 400 diameters.) (Cabot.) 

sides of the tube and over the surface of the blood. To secure the 
serum this clot must be removed with a bit of wire. 

2. Dilution. One drop of the serum is added to forty drops of a 
bouillon culture. The same dropper must be used for each fluid, in 
order that the size of the drops will be equal. The fluids are to be 
mixed intimately in a small test-tube. A drop of this mixture of cul- 
ture and serum is placed upon a cover-glass, which is then inverted 
over a hollow ground slide and examined under the microscope with 
the immersion lens. Within twenty minutes clumping should take 
place. If the reaction does not take place a new mixture should be 
made, in the proportion of 1 to 20 or 1 to 10. If there is no reaction 
with this dilution the test is negative. Instead of making successive 
mixtures three tubes can be prepared at once, containing ten, twenty, 
and forty drops each of the culture. A drop of serum can be added 
and the test conducted as above. 

3. Examination of Slide. A No. 7 Leitz dry lens or oil-immer- 
sion lens can be used with a No. 3 or No. 4 eye-piece. Artificial light is 
preferable to daylight ; if the latter is used a small aperture diaphragm 
is the best. It is very necessary that the slide and cover-slip should 
be thoroughly cleansed. 



236 GENERAL DIAGNOSIS. 

The Reaction. In a complete or typical reaction the field shows 
the presence of large clumps of bacilli isolated and motionless. (See 
Fig. 47.) No motile bacilli can be seen. The clumping may occur 
instantaneously or gradually. If the reaction is very marked, Greene 
states a mottling can be seen with the naked eye. Clumping and 
cessation of motion are the essentials of the reaction, providing they 
take place within a certain time, and notwithstanding a certain degree 
of dilution of the serum. When the reaction is feeble small clumps 
appear, or, as Widal calls them, agglutination centres. As the field is 
studied bacilli are seen moving toward the centres and gradually rang- 
ing themselves in loose masses, sometimes like the spokes of a wheel. 
Durham has called attention to a peculiar spinning motion of the 
bacilli around one of its own ends, Avhich is seen in some of the fields 
in which a few isolated bacilli remain. Such movements occur at the 
margin of the clump. 

It is very necessary to examine a drop of the pure culture before 
the addition of any serum, to make sure that clumping has not already 
taken place, particularly if the culture is old or has undergone sedi- 
mentation. It is desirable that the bacilli should be isolated and 
actively motile. 

Time Limit and Dilution. As Cabot forcibly states, only when 
clumping occurs within a certain time and in a certain degree of dilu- 
tion is it of diagnostic importance. The test is quantitative and not 
qualitative. The degree of dilution of 1 to 10 is quite sufficient if the 
time-limit for the reaction is at least fifteen minutes. Any clumping 
of typhoid bacilli which takes place fifteen minutes after one part of 
serum has been added to ten of the culture gives a probable typhoid 
reaction. Various observers select different dilutions. Thus, Wilson 
and Westbrooke make a dilution of 1 to 50 with a two-hour time- 
limit. Durham uses a dilution of 1 to 17 or 1 to 20. 

Instead of the serum from the blood the serum of a blister may be 
used, or the serum from blood which has been drawn directly from a 
vein with antiseptic precautions. 

The whole blood can also be used in a fluid state. A drop of the blood 
can be drawn directly into ten drops of the culture previously meas- 
ured. This method is of great advantage for rapid work. The same 
dropper should be used for measuring the culture and subsequently 
the blood. With the microscope at the bedside the test can be made 
rapidly with but little risk of failure. 

A still more convenient method consists in the employment of the 
pipette, used for diluting the blood in counting leucocytes. The blood 
from the finger is drawn up to the 0.5 or 1.0 mark on the stem, and 
the bulb then filled with distilled water. The mixture is then blown 
into a small test-tube. As the dilution has already been made, a drop 
of bouillon culture or a small portion of an agar culture may be added 
to it directly and examined as above. 

The Reaction with Dried Blood. We owe to Wyatt Johnston, of 
Montreal, the great credit of working out this simple but accurate 
method of performing the reaction. It is of special value for sanitary 
work where blood has to be sent by mail for examination. The method 



THE DATA OBTAINED BY OBSERVATION. 237 

is simple. The blood is collected on glass or glazed paper. In this 
manner it can be preserved for an indefinite time and transported 
easily. If the drop of blood is dried on a glass slide it can be dissolved 
by the addition of a little water and then the culture added in the way 
previously described. If the drop is dried on paper it can be cut out 
with a pair of scissors and rubbed up in a watch-glass with one drop of 
water. When the blood is dissolved ten drops of culture are added, 
and the examination is carried on as in the previous method. 

Some operators collect the blood in the eye of a wire loop of a given 
size, and after placing it on a glass, dilute with water in the proportions 
desired, ten loopfuls of water being the amount usually selected to mix 
with the drop in the wire loop. Wilson and Westbrooke have modi- 
fied Johnston's technique as follows : They use a bit of platinum 
wire, number 19 gauge, one end of which is bent into a loop, the 
inside diameter of which is 2 mm. The loop is used to collect the 
blood, several drops of which are deposited on a bit of aluminium foil, 
number 40 gauge, 5 cm. square. After the blood is dried the foil is 
rolled up. At the laboratory the bit of foil is then cleared of blood, 
which flakes off easily. One mgm. of dried blood and 200 mgm. of 
distilled water are weighed out and mixed. This gives an exact dilu- 
tion of 1 to 200 by weight ; 1 to 50 dilution by volume. A hanging 
drop of the dilution is inoculated with the bouillon culture and exam- 
ined. The time limit is two hours. 

It is essential for the success of the reaction that a pure culture of 
the typhoid bacillus should be employed. The most suitable culture 
for diagnostic work is that which is the most actively motile. It is 
true, however, that many observers recommend the attenuated cultures. 
They hold that an actively motile culture is too sensitive, and may cause 
clumping even with normal serum. If a fresh culture is kept at room 
temperature and transplanted every two or three days the culture main- 
tains its motility and sensitiveness for a long period. The incubator 
bouillon cultures of twelve hours' growth are probably the most avail- 
able. Johnston, whose experience is worth following, thinks the mo- 
tility must not be excessive. He reduces the motility of the bacilli by 
transplanting his agar cultures once a month, growing them at room 
temperature. The bacilli from this culture, grown for twenty-four 
hours on bouillon, show a slight gliding motion, which differs from 
the darting motion seen in an active culture. The bouillon, Johnston 
holds, should be slightly acid, contrary to the general rule, which states 
that it should be neutral. It is quite necessary that the bouillon cul- 
ture should be young — that is, twelve to twenty-four hours' duration 
in the incubator or two days at room temperature. When a culture 
is made under these circumstances, before it is used it should be free 
from sediment and only slightly turbid. It should also be free from 
any spontaneous clumping and from non-motile or sluggish forms. 

Value. The question may well be asked, What is the value of 
the serum reaction ? Let us answer by referring to typhoid fever 
chiefly. When it is recalled that this reaction takes place in about 98 
per cent, of all cases of typhoid fever, it can readily be seen what a' con- 
stant phenomenon it is in the course of continued fever. As a symp- 



238 GENERAL DIAGNOSIS. 

torn, therefore, it is one of the most constant. Its presence, however, 
cannot be determined in a large number of cases before the eighth or 
tenth day. It has been found as early as the third day, and, on the other 
hand, may be absent until after convalescence has set in. In a large 
majority of cases the reaction appears, however, before the fourteenth 
day. In a few instances, as Widal pointed out, the reaction disappears 
as soon as the temperature remains normal. In other instances it may 
continue several months, and in rare cases has been found as long as 
ten years after the disease. 

It is thus seen that the presence of the serum reaction is a valuable 
diagnostic symptom of some diseases, and notably of typhoid fever. 
Its absence, however, does not disprove the presence of the disease. 
Sometimes the blood of a patient ill with some other disease, who has 
previously had typhoid fever, may give a positive reaction, and thus 
lead to a false diagnosis. Absence of reaction in a supposed case of 
typhoid fever implies, in 98 per cent, of all cases, that this infection is 
not present, providing, of course, that the technique is correct and 
that repeated examinations have been made. In the following diseases 
the serum diagnosis is employed : (1) Glanders ; (2) Malta fever; (3) 
yellow fever ; (4) cholera ; (5) relapsing fever ; (6) typhoid fever. 

4. Leucocytosis. The presence of leucocytosis is characteristic of 
many infections, and, on the other hand, is against not a few of the 
most common of the infectious disorders. Accurate study of the num- 
ber of white cells has led to fairly definite conclusions as to the diag- 
nostic value of their increase or their diminution. The method of 
determining the number is described in the chapter on Diseases of 
the Blood, which may be referred to in order that the student may 
also learn the circumstances under which leucocytosis occurs physio- 
logically. Pathologically we find inflammatory leucocytosis or the 
leucocytosis of infectious disease occurring with such frequency as to 
be diagnostic. A classification of the degree can be roughly made only. 
1. In Asiatic cholera, relapsing fever, scarlet fever, diphtheria, syphilis, 
and erysipelas, leucocytosis occurs to a moderate degree. 2. In pneumonia, 
smallpox in the stage of suppuration, septicaemia, actinomycosis, trich- 
inosis, glanders, beri-beri, acute rheumatism, cerebro-spinal meningitis, 
and gonorrhoea it is also found, but more constant and more marked. 
3. In all pyogenic infections, especially abscesses, in inflammations of 
serous membranes and in gangrenous inflammation usually due to strep- 
tococci or staphylococci infection, leucocytosis is great. 

The significance of leucocytosis depends not alone upon the number 
of the white cells, but also upon their rise and fall in the course of the 
disease. The amount of local inflammation attending the infection is 
not a measure of the amount of leucocytosis. Moreover, the degree of 
fever does not affect the leucocytosis. Fever may occur without in- 
crease in the white cells, and the opposite condition may also obtain. 
When leucocytosis and fever are due to the same infection they may 
rise and fall together, as we often see in cases of pneumonia. 

Absence of Leucocytosis. While the presence of leucocytosis is sig- 
nificant of various infections, its absence is likewise of great significance. 
Hence if there is no leucocytosis it is possible either typhoid fever,. 



THE DATA OBTAINED BY OBSERVATION. 239 

malaria, influenza, measles, rotheln, or tuberculosis are present. The 
blood-count can in this manner be employed to distinguish typhoid 
fever, in which there is an absence of leucocytosis from a pyogenic 
infection, as appendicitis in which the other signs and symptoms 
may be quite similar. Pneumonia, on the other hand — an infection 
characterized by great leucocytosis — may in this manner be distin- 
guished from tuberculosis, in which there is an absence of leucocytosis. 

When leucocytosis occurs in the course of any disease in which it is 
normally absent it is an indication of a complication. In typhoid 
fever it is an indication of intestinal perforation and peritonitis, because 
of a mixed infection. On the other hand, a fall of leucocytes in a 
disease in which they are increased is suggestive of localization of the 
infection, as the " walling off " of the abscess in appendicitis. Such 
fall in pneumonia is of grave prognostic omen. 

5. For direct bacteriological examination of the blood culture 
methods are resorted to. After the skin has been cleansed and made 
aseptic either a considerable portion of blood is withdrawn from a vein 
with a sterilized hypodermatic needle or blood is directly drawn with 
the instrument described by Ewing. After the blood is thus removed 
it is transferred to the various media, and its further treatment is carried 
on in accordance with bacteriological methods. (See Cultivation of 
Micro-organism s . ) 

Examination of Pathological Secretions and Excretions. 

Microscopical examination, with and without staining, and culture 
methods are employed, as detailed in the sections to follow : 

In nasal discharges the bacillus of diphtheria, of glanders, of tuber- 
culosis, and of the pneumococci, as well as pyogenic micro-organisms, 
are found. 

In the mouth the micro-organisms peculiar to that cavity and the 
micro-organisms of actinomycosis may be found. 

In the fauces and pharynx the bacillus of diphtheria and pyogenic 
micro-organisms are discovered. 

The sputa (see Disease of Lungs) yield the tubercle bacilli, the pneu- 
mococcus, the bacillus of influenza, and actinomycosis. 

The fceces (see Disease of Intestines) are examined for the bacillus 
coli communis, the spirillum of cholera Asiatica, bacillus typhosus, and 
tubercle bacillus. 

The urine. Pyogenic micro-organisms, tubercle bacillus, typhoid 
bacillus, the pneumococcus, and gonococcus are found in the urine. 
They are secured by cover-slip preparations of the pus, or by culture 
methods, as described in the section devoted to Diseases of the Kidneys. 

Examination of the Products of Infectious Inflammation - 
Material Secured by Exploratory Puncture. 

Material removed by exploratory operation or puncture may be 
serous, bloody, or purulent (See Chapter XXI.) It must be examined 
bacteriologically, microscopically, by culture methods, and by inocula- 
tion. Serous fluids are not usually productive of bacteria when exam- 



240 GENERAL DIAGNOSIS. 

ined unless treated by sedimentation, and even then it is often neces- 
sary to inoculate. 

The most important pathological product is pus. Fresh and stained 
preparations are examined, and cultures are taken. We may find only 
one, sometimes two at the same time, of the folloAving micro-organisms : 
1. Staphylococcus pyogenes aureus. 2. Staphylococcus pyogenes albus. 
3. Staphylococcus epidermidis albus (Welch). 4. Streptococcus pyo- 
genes. 5. The tubercle bacillus. 6. The bacillus of syphilis. 7. Ac- 
tinomycosis. 8. The bacillus of glanders. 9. The bacillus of anthrax. 
10. The bacillus of leprosy. 11. The bacillus of tetanus. 12. The 
bacillus of influenza. (See Sputum.) 13. The micrococcus lanceolatus. 
14. The bacillus coli communis. 15. The gonococcus. 

Fresh pus may be examined, but the stained is more satisfactory. 
Staining by the method of Gram is the best, and is as follows : After 
a cover-glass has been prepared and placed in Koch-Ehrlich's solution 
of gentian-violet and aniline water, it is put into a solution of iodine 
and iodide of potassium for two or three minutes. A dull red-brown 
color is produced. It is then rinsed in absolute alcohol for some time. 
The micro-organisms are stained dark blue. The iodide of potassium 
solution is : Iodine, 1 part ; iodide of potassium, 2 parts ; distilled 
water, 300 parts. By this method the various forms of micro-organ- 
isms just indicated are readily brought out. 

Methods of Staining Blood, Pus and Discharges. It is well to 
consider these collectively. Many have been devised, but those of 
clinical value are the following : 

1. Aqueous solutions of basic anilines. 

2. Loffler's alkaline methyl-blue. 

3. Koch-Ehrlich's aniline water solutions. 

4. ZiehPs carbol-fuchsin. 

5. Loffler's method of staining flagella. 

6. Gram's method. 

7. Friedlander's method. 

8. Giinther's method. 

1 . Basic anilines. Aqueous solutions of the basic aniline colors -— 
fuchsin, gentian-violet, and methyl-blue — are used of such strength 
that they can be seen clearly through an ordinary test-tube. They 
may be kept on hand in bottles with pipettes, or made from concen- 
trated alcoholic solutions as needed. They are used by simply drop- 
ping a few drops on the cover-glass preparation, which is held with 
the forceps, allowing it to remain about thirty seconds, and carefully 
washing off in water. It is placed on a slide, bacteria down, and the 
excess of water removed with blotting-paper. 

2. Loffler's alkaline methyl-blue solution. Certain bacteria take a 
stain more readily when an alkali has been added. The formula is as 
follows : 

Concentrated alcoholic solution methyl-blue . . . 30 c.c. 
Caustic potash, 1 : 10,000 100 " 

It is used in the same way as the simple solutions. 

3. Koch-Ehrlich's aniline water solutions. Add to 100 c.c. of dis- 
tilled water, aniline oil, drop by drop, thoroughly shaking after each 



THE DATA OBTAINED BY OBSERVATION. 241 

drop until it becomes opaque. Then filter. Add 10 c.c. absolute 
alcohol and 11 c.c. of a concentrated alcoholic solution of either fuchsin, 
methyl-blue, or gentian-violet. 

4. ZiehFs carbol-fuchsin solution. 

Distilled water 100 c.c. 

Carbolic acid ......... 5 gra. 

Alcohol 10 c.c. 

Fuchsin 1 gm. 

The use of these various stains will be described in the description 
of the different bacteria. 

5. Loffler's solution for flagella. 

Tannic acid, 20 per cent 10 c.c. 

Cold saturated solution ferric phosphate . . . . 5 " 
Saturated solution fuchsin . . . . . . 1 " 

A few drops of this solution are placed on the cover-glass contain- 
ing the bacteria and very gently heated until they begin to steam, and 
then the cover-glass is washed off in water. The preparation is then 
stained with aniline water fuchsin. Different bacteria require differ- 
ent reactions, and so a few drops of an acid or alkaline solution are 
recommended to be added as the case requires. As a rule, however, 
the results obtained when neither acids nor alkalies are added are just 
as satisfactory as those following such additions. 

6. Gram's method consists in staining with a Koch-Ehrlich solution 
of gentian-violet for twenty to thirty minutes, and then decolorizing in 

Iodine .......... 1 gm. 

Potassium iodide . . . . . • . . . 2 " 

Distilled water 300 c.c. 

After remaining in this for five minutes the preparations are rinsed in 
alcohol, and the process repeated until the violet color has disappeared. 

For Friedlander's and Grunther's methods, see Sputum. 

To detect spores of bacilli double staining may be employed. The 
preparation is first stained in a hot Ziehl-Neelsen fuchsin solution, 
then decolorized with alcohol containing from 0.2 to 0.3 per cent, 
hydrochloric acid. When stained again with methylene-blue the 
spores appear red and the bacilli blue. 

The " hanging drop." By the examination of colonies in the hang- 
ing drop we learn of the movement of the micro-organism. Place a 
drop of physiological salt solution on a cover-slip, and add a tiny por- 
tion of colony on platinum wire ; place the slip, drop down, on a glass 
slide, in the centre of which is a depression or hollow. Fix the slip 
by applying a thin layer of vaseline around the margin of the depres- 
sion. Care must be taken in focusing that the lens does not break the 
glass, which may be readily done because of its transparency. The 
bacteria are seen in motion ; on account of the motion their position is 
constantly altered. This motion must not be mistaken for the Brown- 
ian movement of suspended articles, which is vibratory from molecular 
tremor. 

Cultivation of Micro-organisms. The object is to isolate the 
pathogenic organism from all other organisms and to exclude organ- 

16 



242 GENERAL DIAGNOSIS. 

isms that may be introduced from without by unclean instruments or 
other means. Pure cultures are thus obtained, 

Culture-media. Experience has taught us that various forms of 
bacteria require different pabulum, and that various nutrient media are 
required for the isolation of different micro-organisms. As to the bac- 
teria hereafter noted, we are familiar with the proper soil for their 
growth. The media used for bacteria of clinical importance are : 
a freshly steamed potato, gelatin, bouillon, agar-agar, milk, and blood- 
serum. They are prepared or mixed in various ways, and other things 
may be added, as a solution of litmus, to determine the reaction of the 
bacterial products. 

Bouillon. Lean beef, 500 gin., soaked in one litre of water for 
twenty-four hours in an ice-chest ; strain through a coarse towel and 
press until a litre of fluid is obtained. Add 10 gm. of dried peptone 
and 5 gm. of salt. Then neutralize with a normal solution (4 per cent.) 
of caustic soda. Boil till albumin is coagulated. Filter and sterilize. 

Nutrient Gelatin. Make bouillon as above (except neutral- 
izing) and add 10 to 12 per cent, of gelatin, and neutralize after dis- 
solving it by heat. Filter. 

If not perfectly transparent, clarify by heating to 60° or 70° C, add 
the whites of two eggs beaten up with 50 c.c. of water ; mix thoroughly 
and boil until albumin coagulates ; then filter. Sterilize and keep in 
flasks or tubes. 

Nutrient Agar. Prepare bouillon complete ; add finely chopped 
agar, 1 to 1.5 per cent. Place in a porcelain-lined iron vessel, mark 
level of fluid, add 250 c.c. of water and boil slowly, with occasional 
stirring, for three or four hours. Keep the fluid up to the mark by 
adding Avater. Take the vessel from the fire and set in cold water. 
Stir until cooled at 68° to 70° C. ; add the whites of two eggs beaten 
up in 50 c.c. of water. Mix carefully and boil for half an hour, keep- 
ing the fluid up to the level. Filter. 

Sometimes 5 to 7 per cent, of glycerin is added. 

Potatoes. Select old potatoes ; scrub under water-faucet with 
stiff brush ; cut out eyes and defects. Then place in 1 : 1000 HgCl 2 
for twenty minutes. Then place in steam sterilizer and steam forty- 
five minutes. Leave them in and steam fifteen or twenty minutes each 
day for three days. Cut with knife sterilized in flame and lay with 
cut surface upward in a sterilized covered dish. 

Another way of preparing potatoes is to cut cylinders with a cork 
borer of such size as to fit loosely in a test-tube. A slanting surface 
is then cut from the junction of the first and second thirds of the cyl- 
inders diagonally to the opposite edge. These are left in running 
water over night, then placed in test-tubes with a cotton plug and 
steamed for forty-five minutes. On the second and third days they 
are steamed fifteen to twenty minutes. 

Milk. It should be sterilized in a steam sterilizer by the fractional 
method. It is a good soil for the tubercle bacillus (Abbott). 

Blood-serum. The original method of preparing blood-serum, as 
recommended by Koch (given in the text-books on Bacteriology), has, 
in this country at least, almost entirely given place to the method of 






THE DATA OBTAINED BY OBSERVATION. 243 

Councilman and Mallory, the popularity of which is clue to the follow- 
ing advantages : By it the serum is more quickly and easily prepared : 
rigid precautions against contamination during collection of serum are 
not necessary, and the resulting medium, while not transparent or even 
translucent (points aimed at in the original method), fully meets all 
the requirements. 

The special points in the method are : the serum is decanted into 
test-tubes as soon as obtained ; it is then firmly coagulated in a slant- 
ing position in the dry-air sterilizer at from 80° to 90° C. ; it is then 
sterilized in the steam sterilizer at 100° C. on three successive clays, 
as in the case of other culture-media. It may then be protected 
against evaporation by sterilized rubber caps or sterilized corks, and 
set aside until needed. 

Unless the coagulation in the dry sterilizer be complete, the surface 
of the serum will be found to be lacerated by bubbles and cavities after 
it has been subjected to the steam sterilization. A similar formation 
of cavities over the surface of the serum will occur if the temperature 
of the hot-air sterilizer, in which it is solidified, is allowed to get above 
90° C, or if it be elevated to this point too quickly. 

It is of no special advantage to have the serum clear, as the admix- 
ture of blood-coloring matter does not affect its nutritive properties. 

Loffler's blood-serum mixture : 

Neutral meat infusion bouillon (see Bouillon) . . .1 part 
Grape-sugar ......... 1 per cent. 

Blood-serum . . . . . . • . . .3 parts. 

Tube-cultures and Plate-cultures. The plate method was intro- 
duced by Koch for the purpose of isolating individual species of bac- 
teria from mixtures. It may be practised either with gelatin or agar- 
agar. Three tubes previously filled with the culture-media are liquefied 
by warming in a water-bath, then cooled to the lowest point at which 
the medium remains fluid. One of the tubes is then held in the left 
hand, A sterilized looped platinum wire inserted in a glass handle is 
taken in the other hand, passed through a flame, and cooled for a few 
seconds. With this a bit of the material to be examined is taken up, 
the cotton plug is removed from the tube with the free fingers, and 
the wire inserted into the medium. Bv rolling the tube it is thor- 
oughly mixed. Then a second tube is inoculated with three loopfuls 
from the first, and a third with three loopfuls from the second. Plates 
have been previously sterilized and placed in covered dishes also care- 
fully sterilized. The plates are levelled and the contents of the tubes 
poured upon their surface. Then they are cooled over ice- water until 
the medium becomes solid, when they are placed in a proper tempera- 
ture for development. In this way the bacteria are sufficiently diluted 
to form distinct colonies from which pure cultures may be obtained. 

A convenient modification of the method is the use of Petri's plates, 
which are flat, round dishes with covers, the bottom of the dish serving 
as the plate. 

Another modification (Esmarch's tubes) is the use of tubes with a 
small quantity (5 c.c.) of the medium. By rolling the tube in the 



244 GENERAL DIAGNOSIS. 

fingers the sides are coated with the media. They are then rolled on 
ice, so that the medium solidifies in a thin layer about its walls. 

Smear- cultures and Stab-cultures. When the bacteria has been 
isolated by one of these methods pure smear-cultures or stab-cultures 
must be made from them. A tube of the proper culture-medium is 
taken in the left hand, a bit of pure colony taken up on a sterilized 
straight platinum needle, the cotton plug removed as above, and the 
needle thrust straight into the medium for a stab-culture, or rubbed 
over a slanting surface of media for a smear-culture. The plug is 
immediately inserted and the tubes transferred to the incubator. 

When pure cultures have been obtained the species are recognized 
by their mode of growth and behavior in different culture-media, the 
reaction produced by their growth, and their appearance under the 
microscope when stained and unstained. 

When nutrient media are inoculated they must be kept at a favora- 
ble temperature. This will be detailed when each micro-organism is 
discussed, as a number of pathogenic bacteria require a definite and 
continuous temperature. 

The primary inoculation will often yield numerous colonies, the 
nature of the bacteria comprising which must be determined by their 
morphology and biological characteristics. It is frequently necessary 
to repeat the process of plating with several of the colonies obtained 
on the original plates, otherwise one cannot always be certain that the 
organism for which he is seeking has been isolated in pure culture. 

Microscopical Examination of Colonies. Just here may be 
stated the methods employed for the study of the morphology of the 
colonies secured by plate and other means of cultivation. 

Cover-glass preparations are made as follows : Place on the cover- 
glass a small drop of distilled water. With a platinum needle take 
up the smallest possible quantity of the colony to be examined, mix 
it with the drop and spread over the surface of glass. Dry under 
cover or by holding with fingers over a flame, the layer of bacteria 
being away from the flame. When dry pass it with forceps- three 
times through the gas or alcohol flame to " fix " the albumin. It is 
then ready for staining. 

Inoculation of Animals. 

Another method of determining the pathogenic character of morbid 
material, as sputum, pus, or exudation, is by inoculating animals with 
a pure culture. This is done either by feeding or injection, as subcu- 
taneous or intravenous, into the peritoneal or pleural cavity, and, in 
rare instances, into the anterior chamber of the eye or into the cranial 
cavity. 

As animals are subject to only a few of the microbic diseases of 
man, many experiments must often be made before a susceptible 
animal is found, and no conclusions can be reached as to the patho- 
logical power of a micro-organism until this point has been determined. 
The clinical course of the artificial disease must be observed to fulfil 
the diagnosis, and the difficulty of reproducing faithfully in animals 



THE DATA OBTAINED BY OBSERVATION. 245 

the clinical manifestations seen in man is often one of the gravest 
obstacles to this method of diagnosis. 

Examination of the animal is made as soon as possible after death. 
The autopsy is made with antiseptic precautions. After the skin is 
removed only sterilized instruments are to be used. The macroscopi- 
cal appearances and the mode and progress of infection are noted for 
the purpose of aiding in the diagnosis. When the organs are exposed, 
material for culture is first obtained by inserting a platinum needle 
through a small puncture in the capsule. Afterward cover-glasses 
may be prepared for immediate examination. Blood is taken from 
one of the cavities of the heart. After the autopsy all remains are to 
be burned and all instruments carefully sterilized. 

Special Bacteriological Diagnosis. The following points must be 
investigated in order to determine the specific nature of the micro- 
organism which is supposed to be the productive agency of the disease 
in question, viz. : The form, — micrococci, bacilli, spirilla, polymorphous ; 
relation to oxygen — aerobic, facultative anaerobic, strict anaerobic ; 
growth in nutrient gelatine — liquefy, do not liquefy, do not grow at 
" room temperature ;" growth on potato ; growth on milk — coagulate 
milk, do not coagulate, etc. ; color of growth — chromogenic, non-chro- 
mogenic ; spore-formation ; movement ; pathogenic power. 

Note. For further information concerning technique the student must refer to the 
work of Abbott on the "Principles of Bacteriology" and to Sternberg's "Manual of 
Bacteriology" for an exhaustive account of the technique, and the morphological and 
bacteriological characteristics of all bacteria, pathogenic and non-pathogenic. 



CHAPTER XVIII. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 

FEVER. THE INFECTIOUS DISEASES 

Infections Not Recognized by Bacteriological or Blood 
Examinations. 

This group includes most of the eruptive fevers which are conta- 
gious and epidemic. Their recognition must be based on data of the 
social history, the duration of the period of incubation, and upon 
the mode of onset and course of the respective infection. They are : 
typhus fever, smallpox, varicella, scarlet fever, measles, rubella, mumps or 
epidemic parotitis, glandular fever, whooping '-cough, rheumatic fever, 
dengue, beri-beri, syphilis, WeWs disease, milk-sickness, miliary fever, foot 
and mouth disease, hydrophobia. 

It must be remembered that other infections are not always recog- 
nized by bacteriological examinations, although if such examination 
gives a positive result the diagnosis is final. The following data 
should be sought for in the diagnosis of any infection, but especially 
in case of failure of the bacteriological methods ; or, if such methods 
are successful, as a control in the diagnosis. 

Social History. In the diagnosis of the infectious diseases valuable 
data are obtained from the social history. 

Age. Thus early age is the period of life in which the eruptive 
fevers are more common ; adolescence, that of typhoid fever and tuber- 
culosis. In the sex, however, we find but little of diagnostic value. 

Exposure. Bearing in mind the possible cause of the disease, we 
inquire for all those circumstances which contribute to the origin of 
the infection. Hence we inquire into the food, the character of the 
water, and other material ingested. We inquire if an opportunity for 
inhalation of infectious material could have occurred, as dried sputum 
from a case of tuberculosis, or if exposure to the patient was possible. 
We learn the hygienic conditions and place of residence (malarial dis- 
tricts, the tropics). The occupation — wool-sorter, hostler, farrier — 
points to the nature of the infection. In short, we inquire if the 
patient has been exposed to any infection. 

The Presence of an Epidemic. We inquire if an epidemic of 
the suspected disease prevails, and if the patient has been exposed to 
the contagion. We consider etiological factors, as the season in which 
the infection prevails. 

History of Previous Infection. In the history of previous diseases 
we inquire if the patient has had previous infections. Some contagious 
disorders rarely take place a second time, as scarlet fever, or measles. 



THE DATA OBTAINED BY OBSERVATION. 



247 



Hence, if the patient has never had them — is not immune — his sus- 
ceptibility is of diagnostic importance. Other infections predispose to 
subsequent attacks, as pneumonia or erysipelas, hence the occurrence 
of a previous attack is important. 

Having secured the data above indicated, we proceed to an exami- 
nation of the patient, noting the length of time since he had been 
exposed to contagion, the mode of onset of the symptoms, and the 
subjective and objective symptoms at the time of the examination. 
These separate data will be discussed in the account of the various 
infections included in this chapter. 

THE ERUPTIVE FEVERS. 

The following infections are characterized by a specific eruption 
which permit them to be given the above title. They are also mem- 
bers of Class I., spoken of in Chapter XVII. The fever, in a measure, 
runs a definite clinical course, and is of diagnostic significance. The 
infection bears such definite relation to the eruption, however, that the 
diagnosis is usually based upon the latter. 

Typhus Fever. 

In this infection the temperature rises rapidly, reaching to 104° or 
105° by the end of the second or third day. It is an acute contagious 
fever, occasionally occurring sporadically, and often becoming epidemic 
in the presence of destitution, filth, over-crowding, and bad ventilation. 

Fig. 48. 



105° 
104° 
103° 
102' : 
101° 
100 r 
99 



3 4 5 



I 



7 8 9 10 11 12 13 14 15 It! 17 18 



7- 



h 



t 



% 



1 



Typhus fever— typical. (Doty.) 



It is characterized by abrupt onset with chill or with chilliness, a rapid 
rise of temperature, lassitude, headache, and pains in the back and 
limbs. On the fourth or fifth day a peculiar spotted eruption appears, 
which at first is macular and subsequently petechial. It is further 
characterized by adynamia or ataxia, low muttering delirium, a suf- 



248 GENERAL DIAGNOSIS. 

fused, heavy, drunken expression of countenance, by the absence of 
local disease, and by a crisis which occurs on or about the fourteenth 
day. 

Typhus fever is variously known as ship fever, jail fever, camp fever. 

The period of incubation is usually about twelve days ; it may be 
five or eight days, or even a shorter time, depending upon the viru- 
lence of the poison and the susceptibility of the patient. Malaise may 
precede by a day or two the onset of the disease. 

Invasion is characterized by headache, faintness, vertigo, chilliness, 
or a distinct rigor, pains in the back and thighs, loss of appetite, 
nausea, constipation, and extreme weakness. The prostration is some- 
times so great as to compel the patient to go to bed at once. The 
puke is frequent, 100 or 140, and in grave cases shows a marked ten- 
dency to become small, soft, and feeble. The patient is restless and 
sleepless, and is annoyed by tinnitus. The expression of the flushed 
face is listless and dull. 

About the fourth or fifth day the typhus eruption begins to appear. 
It consists at first of dull red spots of irregular size and shape. They 
are most numerous on the covered parts. Moore l says they are 
detected first near the axillae and on the wrists, then on the sides of 
the abdomen, afterward on the chest, back, shoulders, thighs, and 
arms. The skin is also mottled by another crop of maculae under the 
skin (" mulberry rash "). 

When the disease is fully developed the face is flushed, the conjunc- 
tivae red, the pupils contracted, so as to resemble pin-holes (" ferrety 
eye "), the tongue dry and brown, the teeth covered with sordes, the 
skin dry, hot, and stinging to the touch. The patient lies upon his 
back oblivious to all his surroundings. Headache has given place to 
delirium, which may be wild and fierce, but is more commonly low 
and muttering. There are marked ataxic symptoms — subsultus ten- 
dinum, tremors, picking at the bedclothes. Incontinence of urine and 
faeces sometimes occurs. The breathing is frequent, shallow, and noisy, 
and the pulse frequent, soft, and feeble. The macular rash now 
becomes petechial. The patient is in a typical " typhoid state." The 
stupor may gradually clear up, or, on the other hand, deepen into 
coma ; or the patient may die from progressive weakening of the 
heart, with or without pulmonary complications. 

In the majority of favorable cases, on or about the fourteenth day, 
the first sign of recovery is a sound sleep, from which the patient 
awakes refreshed and rational. The temperature falls with great 
rapidity, the pulse and temperature improve ; a typical crisis has 
occurred. 

Certain objective phenomena of the disease require special mention. 
The eruption is more copious in severe than in mild cases. A dull and 
livid color is a grave sign. Purpura and hemorrhages are sometimes 
met with in bad cases. The eruption does not occur in successive crops. 

The patient seems to be surrounded by a vapor of a pungent, musty 
odor which is peculiar. 

1 Eruptive and Continued Fevers, by J. W. Moore, Dublin, 1892. 



THE DATA OBTAINED BY OBSERVATION. 249 

The heart early shows the effect of the poison. The impulse is 
diminished, and the first sound is less distinct. In grave cases, with 
threatening heart-failure, the sounds are feeble and distant, the impulse 
imperceptible. 

The pulse is usually very much more frequent than normal, but may 
be abnormally slow (50 and even 30 per minute) ; this is sometimes a 
bad sign. 

The weak heart and prostrate position of the patient favor conges- 
tion, with oedema of the lungs. This condition is common. 

Digestive symptoms have already been referred to. Vomiting, tym- 
panites, and diarrhoea are rare, and still more so is intestinal hemor- 
rhage. 

The urine is scanty and high-colored. Slight albuminuria is common, 
and a few casts are found, but distinct nephritis is unusual. Convul- 
sions, when they occur after the first week, are almost always uroemic 
and almost invariably fatal. They may be due to retention of the 
urine, as recorded by Stokes and Corrigan. 

The duration of the disease is from six to fifteen days ; the average 
period is twelve to fourteen days. An abortive form is met Avith in 
some epidemics, the disease being of a mild type and subsiding at the 
end of a week. In some cases so large a dose of the poison is absorbed 
by the patient that he is stricken down in a few hours or a few days. 
To this form the name " blasting typhus " has been appropriately 
given. The most important complications are hyperpyrexia, laryngitis, 
bronchitis, and congestion of the lungs, extreme ataxia or profound 
adynamia, nephritis, heart-failure, and parotitis, or other inflammatory 
glandular swellings. 

Laryngitis with oedema is a very rare but very dangerous complica- 
tion. 

Diagnosis. Cerebrospinal fever is distinguished from typhus fever 
by greater intensity of the headache, by retraction of the head and 
hyperesthesia, by greater liability to vomiting, and by the absence of 
the macular petechial eruption and the drunken, besotted aspect of 
typhus fever. In cerebro-spinal fever the patient suffers with photo- 
phobia, and is liable to local palsies of the eye-muscles (strabismus) and 
to general convulsions. Convulsions do not occur in typhus except 
from a complicating nephritis or retention of urine. 

Uraemia is distinguished from typhus by the preceding history, by 
the absence of high temperature, and by the presence of oedema of the 
face or extremities, a history of vomiting or diarrhoea preceding the 
stupor. The condition of the urine and the absence of eruption are 
the final tests. 

Pneumonia is distinguished by the frequent respiration and rela- 
tively slower pulse, and by the local physical signs and absence of 
eruption. 

Typhoid fever is distinguished by its slow onset and marked 
abdominal symptoms. The eruption of typhus is petechial and comes 
out on the fourth or fifth day ; that of typhoid fever consists of rose- 
spots and appears on the seventh or eighth day. In typhus fever 
the severe initial chill, the sudden onset, the greater prostration, and 



250 



GENERAL DIAGNOSIS. 



the earlier appearance of cerebral symptoms are helpful in distinguish- 
ing it from tvphoid fever. 

Variola. 

The temperature in variola, or smallpox, pursues a definite course, 
which renders it of value in the diagnosis. Its sudden rise to an 
unusual height without local inflammation but with severe backache is 
significant. Its fall with the appearance of the eruption, followed in 
two or three days by a secondary rise, is very characteristic. 

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Temperature in smallpox. Adult ; mild case. 

Variola, or smallpox, is a specific infectious and contagious fever, 
beginning abruptly with chill, high temperature, headache, vomiting, 
sweating, and intense pain in the back. On the second or third day 
of the disease a characteristic shot-like, papular eruption appears, the 
papules rapidly developing first into vesicles and then into pustules ; 
with the appearance of the rash the temperature falls, but rises again 
toward the end of the week in the pustular stage (fever of maturation 
or suppuration). The contents of the pustules are discharged, crusts 
form and are cast off about the eighteenth day. The disease may be 
accompanied by a number of complications, particularly hemorrhages 
into the skin (purpuric smallpox) and from the mucous membranes 
(hemorrhagic smallpox), both forms being popularly called black 
smallpox. For convenience of description the disease may be divided 
into four stages : (1) Incubation, (2) invasion, (3) eruption, (4) des- 
quamation. 

Incubation. This stage lasts from ten to fourteen days, and is 
usually unaccompanied by any symptoms except, toward its close, by 
malaise. 

Invasion. The invasion is abrupt, and is marked by chilliness or 
a distinct rigor, headache, severe pain in the lumbar region, and some- 
times delirium or convulsions, especially in children. The most promi- 



'3 



> 
< 




m 



H ° 

<D 

Q o 
o 

A S 





C 
OS 



THE DATA OBTAINED BY OBSERVATION. 251 

neut symptoms are the excruciating headache and backache. The tem- 
perature usually rises rapidly to 10-4° F. or higher in the first twenty- 
four or forty-eight hours. (See Fig. 49.) Headache and backache 
continue ; there are pain in the epigastrium, a coated tongue, loss of 
appetite, nausea or vomiting, constipation, and copious perspiration. 
Prostration is extreme. Erythematous eruptions are not uncommon, 
especially on the inner surfaces of the legs and thighs. Petechia are 
found in Simon's triangle, the base of which is at the umbilicus and 
apex at the knees. 

The stage of invasion lasts generally three days ; but it may be 
shortened to two in very severe cases or lengthened to four in very 
mild ones, and in complicated and hemorrhagic cases it merges into 
the stage of eruption. (See Plate IV.) 

Eruption. The characteristic eruption of smallpox appears first as 
minute specks resembling flea bites. These in two or three days 
develop into small papules which feel like shot under the skin. In a 
day or two more the papules become vesicles, at first containing a 
clear fluid, which, however, rapidly becomes turbid ; they are umbili- 

FlG. 50. 




Discrete variola on the sixth day of eruption. (Welch.) 

cated. In the course of another day or two the vesicles have become 
pustules and are globular in shape. The period of ripening or matu- 
ration, when pustulation is at its height, lasts about three days ; it is 
characterized by a marked secondary fever, the temperature rising as 
high as, or higher than, in the onset of the disease. The pustules now 
begin to dry up (desiccation) and form dry scales or scabs, which are 
cast off toward the end of the third week of the disease (eighteenth 



252 GENERAL DIAGNOSIS. 

day) ; when the pustules have been deep enough to involve the true 
skin, characteristic scars, called pits, are left. 

The eruption appears on the forehead, along the margin of the hair, 
and in the scalp, then over the rest of the face, especially about the 
nose and lips, subsequently progressing over the rest of the body from 
above downward. The eruption is most abundant upon the face and 
hands, often being confluent here when discrete elsewhere. The face 
may appear horribly swollen, bloated, and disfigured, and both face 
and hands are extremely painful from the great distention and the 
pustules, which are really small dermal abscesses. 

Varieties. Three varieties of variola, depending upon the number 
and disposition of the pocks and upon the presence of complications, 
are recognized : (1) Discrete ; (2) confluent ; (3) malignant. 

In discrete variola the pocks are not numerous, and are separated 
from each other by intervening healthy skin. 

In confluent smallpox the pustules are close-set, occupy almost 
the whole body, and coalesce, so that the face looks as though covered 
with a black, rough mask ; the mucous membranes are also covered. 
The symptoms of the invasion are intensified, and the eruption may 
appear before the third day. Patients are liable to suffer with profuse 
salivation, uncontrollable vomiting or diarrhoea (especially in children), 
and with delirium, which is often violent and destructive. The face is 
dreadfully swollen and the eyelids may slough ; the feet and limbs 
also may be swollen and painful. There may also be severe bronchitis 
and pneumonia, abscesses, extensive sloughing, and a pysemic condition. 

Malignant, or black, smallpox is a form in which the blood is 
so altered that hemorrhages into the skin or from the mucous mem- 
branes occur. In the former case there are petechia? and ecchymoses 
upon the skin ; in the latter more or less profuse hemorrhages occur 
from the womb, kidney, bowels, lungs, and stomach. The mind of the 
patient remains clear and he is conscious of his peril. The eruption is 
delayed or does not occur at all. 

Varioloid is a mild form of smallpox occurring in a person protected, 
but not completely, by previous vaccination, or in a person who, from 
other causes, does not possess the average susceptibility. It is charac- 
terized, apart from its mildness, by great irregularity in the develop- 
ment of the symptoms. The initial symptoms, as a rule, are as severe 
as in ordinary smallpox. Prodromal eruptions, especially the erythe- 
matous, are very common. The eruption may appear first on the face, 
or on the chest and trunk first, and later upon the face. The fever 
subsides with its appearance. The eruption passes from the papular to 
the vesicular stage, as in ordinary smallpox ; but here the process, as a 
rule, ceases, the vesicle drying up on the fifth or sixth day of the erup- 
tion. If pustules form they do not reach their full development. The 
eruption is always discrete. There is usually no secondary fever. 

Diagnosis. When fully developed, smallpox will not be mistaken 
for any other disorder. In the initial stage, however, there may be 
doubt whether the disease will prove to be pneumonia, cerebro-spinal 
meningitis, or typhus. If the patient has been exposed to smallpox 
and is unprotected by vaccination, and he is suddenly seized with a 



THE DATA OBTAINED BY OBSERVATION. 253 



chill, high temperature, and excruciating pain in the lumbar region, 
there is great probability in favor of smallpox. If the patient has 
complained of headache, pains in the ankles and other joints, and is 
seized with a severe rigor, explosive vomiting, and great weakness of 
the limbs, the chances favor meningitis in the absence of known expo- 
sure to smallpox. In pneumonia, vomiting, chill, and high tempera- 
ture succeed each other, but excruciating backache is wanting, and, on 
the other hand, the respiration is increased out of proportion to the 
pulse, and even in this early stage there may be cough and roughening 
of the respiratory murmur on one side. 

Typhus fever begins abruptly with chill and high temperature ; but 
the eruption which comes out on the fourth or fifth day is first macular 
and later petechial, the temperature does not fall with the appearance 
of the eruption, the aspect of the patient is drunken and stuporous, the 
conjunctivae are injected, the eye ferrety, the skin dry, hot, and biting 
to the touch (calor mordex). 

In the papular stage of the eruption it may be mistaken for measles ; 
but the red, swollen, bleaiveyed, photophobic little patient with measles, 
with the characteristic coryza and obstinate cough, presents a very 
different appearance from that seen in variola. Moreover, the eruption 
of measles is relatively flat, smooth, and velvety ; that of smallpox is 
acuminate, hard, and shot-like. The temperature in smallpox falls as 
the eruption appears ; that of measles remains high and even increases. 
The papules of measles do not develop into vesicles. 

In the vesicular stage varioloid may be mistaken for ehickenpox. In 
the latter the eruption is practically vesicular from the start, occurs 
without prodromata, appears first upon the chest and neck, later upon 
the face and scalp, is usually very scanty, and rarely becomes umbili- 
cated or pustular. There are, however, severe forms of varicella, in 
which fever, restlessness, and cough precede the appearance of the rash, 
which is copious, some of the vesicles being inflamed at the base, some 
umbilicated, and some with purulent contents. These cases are most 
common in scrofulous children whose hygienic surroundings are bad. 
In such cases the diagnosis cannot be made from the eruption. A con- 
sideration of the following points must decide : 1. History of exposure 
to varicella on the one hand or smallpox on the other. 2. The pres- 
ence or absence of effective vaccination or of scars of antecedent vari- 
cella. 3. The age of the patient ; smallpox occurs at all ages, varicella 
only in childhood. 4. The discovery among neighboring children of 
varicella or varioloid. 5. The rapid evolution of a varicella pock. 

Varicella. 

Varicella is one of the infections of childhood in which the febrile 
course is very mild. It is an acute specific infectious fever, occurring 
almost exclusively in children, and characterized by the appearance, in 
successive crops, of colorless or pearly vesicles, which dry up and are 
shed in from two to five days. It is attended with very little constitu- 
tional disturbance. A second attack is extremely rare. 

The incubation is generally about two weeks, but may be one or 



254 



GENERAL DIAGNOSIS. 



three weeks. In ordinary cases the first evidence of the invasion of 
the disease is the appearance of the eruption. In other cases, the 
severer ones, the child may be noticed for some hours or several days 
to be indisposed, complaining of loss of appetite, nausea, headache, and 
vague muscular pains. The fever is almost always moderate — 100° 
to 101°. 

The eruption consists first of hypersemic macules, compared by Trous- 
seau to the rose-rash of typhoid fever. These macules rapidly become 
first papules and then vesicles. The papules are not hard as in variola. 
They appear at first upon the chest, neck, face, and scalp, then upon the 
trunk and limbs. The development of the vesicles is so rapid that the 
eruption appears vesicular from the start. The vesicles vary in size 
from a pinhead to a small pea. They are very superficial, and usually 

Fig. 51. 




Varicella oil the fifth day of eruption. 



rest upon a base that is slightly or not at all hypersemic. The contents 
are at first watery, but subsequently become pearly. The reaction of 
the fluid is alkaline. Distinct mnbilication is rare, and pustulation 
still more rare, but both occur. The vesicles almost always dry up and 
form scabs, yellowish or brownish, which drop off, leaving a slightly 
reddened, sometimes depressed spot. Sometimes the vesicles are to be 
seen upon the buccal mucous membrane and upon the throat. While 
most of the eruption appears on the first or second day, fresh vesicles 
continue to appear for several days. 

Desiccation usually occurs by the fourth or fifth day, and may be 
present in the first day or two. As the eruption appears in successive 
crops, often all stages, from the initial macule to the dried scales, can 
be seen in one case. 

Usually the vesicles are widely scattered, a dozen or two over the 
entire body. They are most numerous upon the back, and may be as 
close together as in discrete variola. 

In scrofulous and badly nourished children the lesions are more in- 
flammatory and pustules are more common. If they are scratched, 
ulceration ensues. A gangrenous form has been described by Eustace 
Smith and others ; the cases are apt to be fatal. 



THE DATA OBTAINED BY OBSERVATION. 255 

In ordinary cases during the eruption the child is rarely more than 
indisposed ; complications are rare, and the prognosis most excellent. 
The physician is not often consulted except to have his opinion as to 
the diagnosis. (For the differential diagnosis from smallpox, see 
Variola.) 

It is distinguished from vesicular and pustular eczema by the fever, 
the symmetrical grouping and discrete character of the lesions, the 
comparative absence of itching and burning, and its shorter course. 

Impetigo is distinguished by the absence of fever, the more local 
character of the eruption, and the fact that it is generally pustular. It 
is more common upon the face and hands than is varicella. 

Scarlatina. 

In this eruptive fever the course of the temperature varies some- 
what with the severity of the infection. In many instances fever 
would not be detected without the use of the thermometer. In others 
it may rise to a great height, and even be hyperpyretic. Its onset is 
sudden ; it reaches its greatest height when the eruption is complete. 

The temperature in scarlet fever usually conforms to a clearly defined 
type. The temperature increases gradually to the third or fourth day, 
when the acme is reached. It declines by lysis in a period of four 
days. A seven days' chart would be pyramidal in shape. In septic 
forms (scarlatina anginosa), with ulceration of the fauces, the fever 
continues and becomes remittent. In scarlatina maligna, hyperpyrexia 
is likely to ensue rapidly. 

Scarlet fever is an acute, specific, contagious, and infectious fever, 
characterized by a sudden onset, with vomiting, sore-throat, and high 
fever, followed in twelve or twenty-four hours by a bright-red, puncti- 
form eruption, by a very frequent pulse, by a desquamation which is 
often in large flakes, by a very variable degree of severity, and by a 
large number of complications and sequelae, especially nephritis and 
inflammation of serous membranes. 

Scarlet fever preferably affects children from one to five years of 
age. The liability to it diminishes after the tenth year ; but it is very 
rare under the age of six months. Puerperal women are very suscep- 
tible to the poison, and the existence of open wounds favors infection. 
The disease occurs in epidemics at longer intervals than is true of 
measles. Cases are most numerous in the autumn and winter months. 
The peculiar poison is doubtless a living organism, but it has not been 
isolated as yet. It is very tenacious of life, being capable of infecting, 
through clothing in which it has been retained, months after the cloth- 
ing absorbed the poison. 

Few diseases vary so greatly in severity in different cases and in dif- 
ferent epidemics. It may be the mildest or most malignant of diseases. 

The period of incubation is remarkably short, generally from three 
to five days ; but it may be a few hours, and, in exceptional cases, six 
days. 

The invasion is abrupt. It is very common to be told that a child 
was apparently well on going to bed, but awoke in the middle of the 



256 



GENERAL DIAGNOSIS. 



night, vomiting profusely and complaining of sore-throat. The child 
is found in the morning with a temperature of 103° or 104°, a pulse 
of 120 to 140, and a scarlatinal eruption beginning to show upon the 
neck and upper part of the chest. Close observation in such cases 
might have discovered that the child was feverish on going to bed, and 
that he had been somewhat chilly before that. Onset with decided 
chill, vomiting, and nervous symptoms indicate a severe case. 



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Scarlet fever. Mild attack ; intense eruption. 



The subjective symptoms of scarlatina are few ; they consist usually 
of pain in swallowing, with stiffness of the neck-muscles, some head- 
ache, thirst, malaise, and a moderate amount of weakness. In the 
eruptive stage the skin itches, burns, and is frequently hypersesthetic. 

The objective symptoms and their order of succession are very charac- 
teristic. Vomiting is the rule, except in mild cases, and hence is of 
importance in diagnosis, especially in otherwise doubtful cases. The 
temperature is high at the onset, frequently 103° or 104°. It falls a 
degree or so in the morning ; but the following evening, when the 
eruption is usually at its height, it rises to 104° or 105°, and then 
gradually falls to normal in the course of a week in ordinary cases. 
(Figs. 34 and 52.) 

The pulse-rate is characteristically frequent, being 120 to 160 oftener 
than slower. This frequency is not an indication of danger. 

The blood shows a leucocytosis, beginning on the first day and con- 
tinuing through convalescence. A close relationship exists between 
the degree of leucocytosis and the rash. Suppurative complications 
tend to increase the number of white cells. The finely granular eosino- 
philes are greatly increased during the first few days. The mononuclear 
cells and lymphocytes are diminished at first, but after a short time 
their percentage increases. 

The throat exhibits a uniform flush extending over pharynx, tonsils, 
soft palate, and sometimes forward on the hard palate, nearly to the 



THE DATA OBTAINED BY OBSERVATION. 257 

teeth. Sometimes dark-red points can be distinguished on the soft 
palate. The tonsils are inflamed and projected toward the median line 
from each side. Frequently the mouths of the follicles are blocked by 
a creamy-white exudate. It is not uncommon to find a severe follicu- 
lar tonsillitis at the first visit. 

The tongue is at first covered with a thick, creamy fur, through which 
enlarged red papilla? show. The enlarged papilla? look like small 
grains of red pepper sprinkled on the tongue. Sometimes the papilla? 
are elevated and have a button-like appearance. The symptoms 
appear very early in the disease, and may continue for three or four 
weeks. The coating soon disappears from the tip, leaving it bright 
red — the " strawberry tongue." 

The skin is hot and dry. The characteristic eruption usually appears 
within twenty-four hours, often within six to eighteen hours, of the 
chilliness or vomiting which marks the onset. Sometimes it comes 
out very slowly, seeming to be just ready to appear, but not appearing 
in its full development for four or five days. 

The intensity of the eruption varies from a scarcely perceptible ery- 
thema to the color of a boiled lobster. Usually its intensity varies 
with the severity of the disease. In ordinary cases the patient appears 
to be covered with a uniform red efflorescence ; but a closer inspection 
shows that there are darker red spots between which the skin is more 
or less erythematous. It is first seen about the ears and neck, and 
spreads with great rapidity, covering the entire body in a day. It is 
most intense upon the trunk and flexor surfaces. Upon the extensor 
surfaces the punctate character is better seen. Pressure causes the 
reduess to disappear, but it immediately reappears. Papular and vesic- 
ular forms of eruption are also seen. The physiognomy of the disease 
is peculiar. The circle about the eyes, nose, and lips remains pale, 
and in marked contrast with the rest of the fiery red face. Itching 
and burning are annoying symptoms at times. The eruption fades 
gradually, in ordinary cases disappearing, except when there is press- 
ure or irritation toward the end of the week. 

The eruption is succeeded by desquamation, which is extensive in 
proportion to the intensity of the eruption. The flakes are larger than 
in measles, and in severe cases the epidermis may come off in long 
strips. About the hands and feet this shedding is sometimes so great 
as to be compared to a glove. This stage may be protracted for sev- 
eral weeks, danger of infection lasting as long as desquamation con- 
tinues. 

The urine is at first scanty, high-colored, and febrile. Later, when 
desquamation is in progress, there is great liability to albuminuria as a 
complication. 

Varieties. In addition to the ordinary form already described scar- 
latina exhibits many irregular forms. There may be only a sore-throat 
or follicular tonsillitis. If a rash is present, it is very faint, and hence 
easily overlooked. The diagnosis in such cases must be made from 
the fact of exposure to infection and from the appearance of the throat. 
The occurrence of vomiting is very important in the diagnosis, as it is 
rare in ordinary pharyngitis and tonsillitis. Often such cases escape 

17 



258 GENERAL DIAGNOSIS. 

detection altogether, until possibly a dropsy from scarlatinal nephritis 
indicates their nature. 

Severe diarrhoea may prevent the eruption from developing upon the 
skin. It appears upon the fauces, and the diagnosis is based upon this, 
the pulse and temperature, and the fact of exposure. 

In scarlatina anginosa the strength of the poison is spent upon the 
throat. Pain is great and deglutition difficult. The tonsils are greatly 
swollen, so as almost to occlude the fauces, and their surfaces are cov- 
ered with creamy exudate. The cervical glands are swollen, and there 
is a tense and brawny cellulitis. Sometimes the tonsils become gan- 
grenous, and the cervical or submaxillary glands suppurate or become 
gangrenous, with resulting pyaemia and death. Suppuration may 
extend to the ears and maxillary sinuses. In this form, also, a false 
membrane is sometimes found upon the fauces— post-scarlatinal diph- 
theria. It is probably not due to the Klebs-Loffler bacillus, but to a 
streptococcus. 

In malignant forms the attack is ushered in with chill, followed by 
hyperpyrexia, convulsions, marked ataxic symptoms, or stupor. The 
profound blood-disturbance is shown by the dusky hue of the eruption. 
Some patients lie in coma-vigil, others are very restless and delirious. 
Vomiting and diarrhoea are sometimes superadded. Patients may 
emerge from this condition and succumb later to a nephritis or to grave 
anginose symptoms ; but death in a few days is the rule. In rare cases 
the dose of poison is so enormous that death takes place in a few hours, 
without the appearance of any eruption. 

Complications and Sequelae. The severe local symptoms men- 
tioned under the anginose variety, together with convulsions, hyper- 
pyrexia, and ataxic symptoms, may properly be regarded as complica- 
tions. Apart from these the most frequent are nephritis and endocar- 
ditis or pericarditis. Nephritis generally appears with the beginning of 
desquamation. It is nearly as frequent in mild as in severe cases, 
probably because the danger of exposure to cold is greater in the 
former, although the scarlatinal poison unquestionably has a selective 
affinity for the epithelium of the kidney. The symptoms do not differ 
from those of acute parenchymatous nephritis occurring under other 
circumstances. In some cases we have weakness, languor, slight fever, 
and prolonged convalescence ; in others, oedema, anuria, convulsions or 
coma from uraemia. Endocarditis is often preceded by tenderness and 
soreness of the muscles and joints — scarlatinal rheumatism. 

Endocarditis and pericarditis develop in the coarse of the fever, 
giving rise to an increase or continuance of the fever, to local pain or 
dyspnoea, and to the usual physical signs. 

Pleuritis and meningitis also may occur. Much more common com- 
plications are otitis, peripheral neuritis, and affections of the joints, 
grouped as scarlatinal rheumatism. Paralyses, peripheral and central 
in origin, are occasional sequels of the disease. Scarlatina is found 
also in association with other diseases. 

Diagnosis. Sudden onset, rapid rise of temperature, persistent and 
causeless vomiting, and sore-throat lead one to suspect this affection. 
The characteristic eruption and its mode of evolution, the rapid pulse, 



THE DATA OBTAINED BY OBSERVATION. 259 

the peculiar tongue, the circle of pallor on the face, are characteristic 
of the eruptive stage. " The appearance of a punctate eruption in the 
axilla and in the groins, together with the congestion of the tonsils and 
a punctate eruption in the roof of the mouth, no matter whether there 
is any eruption anywhere else or not, are positive proofs of scarlet 
fever" (McCollom). 

Unfortunately, all cases do not develop to the same degree, so that 
frequently we must wait for the period of desquamation ; more unfor- 
tunately, for the occurrence of sequelae, as acute nephritis, otitis, or 
adenitis. 

Scarlet fever is distinguished from measles by the mode of onset, which 
is sudden, with chilliness, high temperature, vomiting, and sore-throat, 
and great rapidity of the pulse ; whereas the onset in measles is gradual, 
with coryza, cough, moderate fever, perhaps looseness of the bowels, 
but no sore-throat. The eruption of scarlatina occurs on the first day, 
that of measles on the fourth ; the former consists of dark-red spots 
with intervening erythematous skin, the whole looking at a distance 
like a uniform bright-red flush ; the latter consists of raised, rounded, 
or flattened spots or blotches, velvety to the touch, and, upon the body 
and extremities, grouped in patches with crescentic outlines. The tem- 
perature in scarlatina subsides gradually after the rash has reached its 
height ; that of measles increases until the eruption is complete, then 
subsides by crisis. The rash of scarlet fever persists for six or eight 
days ; that of measles fades as soon as it is complete, on the fourth 
day. In the former, desquamation is in flakes or large strips ; in the 
latter it is branny and nearly invisible. Scarlatina involves by prefer- 
ence the serous membranes and kidneys ; measles the mucous mem- 
branes and lungs. 

Scarlatina has to be differentiated from pharyngitis, tonsillitis, and 
digestive disturbances, attended with vomiting, high temperature, and 
occasionally erythematous eruptions. 

In ordinary pharyngitis and tonsillitis the redness is more apt to be 
confined to the pharynx, tonsils, and arches of the soft palate ; in scar- 
latina it extends as a flush over the soft and hard palate and buccal 
surfaces. In the former, high temperature, a very frequent pulse, and 
vomiting are unusual ; in the latter they are the rule. 

The glands of the neck also are more apt to be involved in the latter. 

In acute gastritis there is usually a history pointing to indiscretion 
in eating, with constipation. The pulse is not so frequent as to suggest 
scarlatina, sore-throat is absent, and any erythema present lacks the 
•characteristic dark-red pomts, and is not followed by desquamation. 

The diagnosis from rubella is difficult at times. It differs from scar- 
latina in presenting mild catarrhal symptoms, sneezing, suffusion of 
the eyes, and cough, with a relatively fleeting eruption. The latter 
perhaps appears most frequently upon the back and chest. Often the 
eruption is the first thing noticed amiss with the child. It more com- 
monly resembles the rash of measles than that of scarlatina, but when 
it resembles the latter most it is apt to be discrete and of a darker red. 
There may be a very intense rash without much constitutional disturb- 
ance, the temperature being lower and the pulse much slower than 



260 GENERAL DIAGNOSIS. 

would be expected in a scarlatina presenting the same appearance. 
Nausea may be present, but vomiting is very rare. The post-cervical 
and post-auricular glands are more commonly enlarged in rubella than 
in mild scarlatina, though this symptom is not invariable. 

Diphtheria is distinguished by its gradual onset, patches of false 
membrane developing upon the fauces early. In anginose scarlet fever, 
with severe follicular tonsillitis, the differential diagnosis is essentially 
the same as between simple follicular tonsillitis and diphtheria (q. v.). 

In addition, the pulse and temperature have a much higher range in 
scarlatina. The erythema of diphtheria is distinguished from the erup- 
tion of scarlatina by its fleeting character and the absence of desqua- 
mation. 

Grave cases which begin with repeated vomiting, convulsions, del- 
irium, and insomnia simulate meningitis ; but a satisfactory cause for 
the latter is lacking, while the excessive heat of the skin, sore-throat, 
very frequent pulse, and early eruption clear up the diagnosis. 

So, also, the onset with vomiting, convulsion, and high temperature 
resembles pneumonia; but in the latter the respiration is proportion- 
ately more frequent than the pulse, with altered breath-sounds and 
percussion-sounds, while sore-throat and eruption are wanting. 

Measles. 

The course of the fever in this affection resembles that of smallpox 
in that after the initial rise of the first twenty-four hours the tempera- 
ture remains normal until the appearance of the eruption on the third 
day. It is an acute, specific, infectious, and highly contagious fever, 
characterized by coryza and bronchitis, a red papular eruption, coming 
out on the fourth day and followed by a branny desquamation about 
the ninth or tenth day. The mucous membranes are especially liable 
to complications. 

Measles occurs in epidemics, especially in cold weather, but indi- 
vidual cases are met with in large cities at all seasons of the year. It is 
so contagious that when one case develops in a household or institution 
almost every person exposed to it and not protected by a previous 
attack acquires it. Children from one to five years of age are most 
susceptible to the poison, but it may occur in utero and in old age ; 
moreover, the same person may have several attacks, showing that one 
attack does not afford the same protection as an attack of scarlatina or 
variola. 

Measles is sometimes found in association with scarlatina and vari- 
cella, but it is especially liable to occur after pertussis. 

The specific cause of the disease has not yet been isolated. 

The period of incubation lasts from eleven to fourteen days. During 
this time the patient may exhibit no symptoms, or may be irritable and 
restless, with disturbed sleep and occasional cough, and looseness of 
the bowels. 

The invasion is marked by cough and fever, and by redness of the 
eyes and lacrymation, sometimes with photophobia, sneezing, and an 
irritating, watery discharge from the nose, which subsequently becomes 



PLATE V. 



Fig. I. 



Fig. II. 





Fig. IV. 





The Pathognomonic Sign of Measles (Koplik's Spots). 



Fig. i. — The discrete measles spots on the buccal or labial mucous membrane, showing the isolated rose- 
red spot, with the minute bluish-white centre, on the normally colored mucous membrane. 

Fig. 2.— Shows the partially diffuse eruption on the mucous membrane of the cheeks and lips; patches of 
pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots. 

Fig. 3. — The appearance of the buccal or labial mucous membrane when the measles spots completely 
coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthema on the skin is at 
this time generally fully developed. 

Fig. 4. Aphthous stomatitis apt to be mistaken for measles spots. Mucous membrane normal in line. 
Minute yellow points are surrounded by a red area. Always discrete. 



THE DATA OBTAINED BY OBSERVATION. 



261 



mucopurulent, and by cough and fever. In short, the early symp- 
toms are those of a severe coryza. These symptoms last from three to 
five days (generally four) before the eruption appears. 

But an eruption is commonly visible upon the base of the uvula and 
soft palate, as raised, discrete dark-red papules, several days before it 
appears upon the body. The peculiar appearance of this eruption has 
been accurately described by Koplik (1897). His observations have been 
corroborated, so that " Koplik's sign " is a well-established fact. Its 
importance can be understood when the necessity for early diagnosis for 
quarantine purposes is realized. This sign appears twenty-four hours, 
forty-eight hours, and even three to five days before the skin erup- 
tion. It precedes the conjunctivitis and begins at the first rise of 
temperature. The eruption appears on the mucous membrane of the 
cheeks and lips. It is not seen on the palate or the fauces. It is at 
first discrete and then becomes confluent. It is at its height when 
the skin eruption appears and is spreading. In strong daylight this 
pathognomonic eruption is seen to consist of small irregular spots of a 



Fig. 53. 





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bright-red color, in the centre of which is seen a minute bluish-white 
speck. The bluish-white speck is very small and delicately colored, 
requiring direct and strong daylight to see it. A combination of the 
speck on the rose-red background is a positive sign of the invasion of 
measles. The spots must not be mistaken for sprue, which is opaque, 
white, coarse, and plaque-like. When the rose-red spots coalesce, 
Koplik describes the appearance of the mucous membrane to be made 
up of large areas of rose-red, studded all over with minute raised bluish- 
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paper illustrate this important sign. (Plate V.) By this sign measles 



262 



GENERAL DIAGNOSIS. 



can be differentiated from rotheln, scarlet fever, aphthous stomatitis, 
forms of erythema and urticaria, drug eruptions, the antitoxin eruption, 
and forms of syphilis. The temperature rises during the first day to 
100° or 102°, or higher, if the case is to be a severe one. The bowels 
are frequently inclined to be loose and the passages somewhat greenish. 
The temperature falls on the second day to normal or nearly normal r 
and then steadily rises until it reaches its acme with the full develop- 
ment of the eruption, when, in uncomplicated cases, it falls rapidly to 
normal. With the coming out of the eruption the coryza increases in 
severity, and cough is a prominent and annoying symptom. It con- 
sists of a series of five or six explosive efforts without expectoration. 
In severe cases the cough is almost incessant, so that rest is much inter- 
fered with. It depends upon a catarrhal inflammation of the entire 
respiratory tract, from the nose to the bronchioles. 



Fig. 55. 



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Measles. Characteristic chart. Female, 



iged twenty-seven. 



Objective Symptoms. The eruption on the body appears first 
about the neck, face, and wrists, and spreads in two or three days over 
the entire body. It is usually most copious upon the face, which is 
swollen, dark-red in color, and closely set with papules, which are 
elevated, rounded at the summits, and feel like soft velvet to the touch. 
When to this picture is added that of a severe coryza with mucoserous 
exudate, which often glues the eyelids together and oozes out upon the 
face, and a corresponding condition of the nasal orifices, the physiog- 
nomy is at once seen to be very unusual. At this stage, moreover, 



THE DATA OBTAINED BY OBSERVATION. 263 

photophobia is often considerable, the child burrowing its head in the 
pillows to escape light. 

The eruption is not apt to be confluent upon the body ; here the 
dark-red, elevated, smooth papules are very distinct. Sometimes they 
are grouped so as to form crescentic outlines. The eruption fades in 
the order in which it appeared, and is followed by a fine branny 
desquamation. With the completion of the eruption the fever 
falls rapidly to or below normal, the coryza and bronchitis im- 
prove correspondingly, and in forty-eight hours convalescence is fully 
established. 

Complications. The complications of measles affect for the most 
part the mucous membranes of the respiratory and digestive tracts. 
The bronchitis, which is always present, may become capillary, or be 
associated with oedema or with areas of catarrhal pneumonia. These 
are the most frequent and the most dangerous complications. Pneu- 
monia may develop while the eruption is coining out, in which case 
the eruption is delayed or the spots have a dusky or bluish hue (black 
measles). More commonly, perhaps, pneumonia is discovered when, 
the eruption being complete, a crisis should occur. 

Epistaxis is not usually dangerous. Profuse diarrhoea is very ex- 
hausting and delays the evolution of the eruption. Severe conjuncti- 
vitis, sometimes with ulceration of the cornea, is not uncommon. 
Otitis media occurs oftener as a sequel than as a complication. Noma, 
or cancrum oris, is a rare complication of measles occurring in ill-fed, 
badly nourished children. It is frequently fatal. 

Convulsions may occur as a complication, especially when pneu- 
monia is developing. 

Sequelae. In cases in which there has been diarrhoea, measles is 
sometimes followed by considerable weakening of the digestive power. 
The catarrh of the respiratory tract, which almost invariably accom- 
panies it, predisposes to the development of whooping-cough and tuber- 
culosis. 

Paralysis may follow measles. It may be central or peripheral in 
origin, but generally is of the hemiplegic type ; cases of acute polio- 
myelitis, acute ascending paralysis, and disseminated myelitis have also 
been reported. 

Varieties. Measles without catarrh is rare. It cannot be recog- 
nized from a measles-like rash, seen in rotheln, except by the occur- 
rence in the neighborhood of other cases of undoubted measles. 

Measles without eruption is to be recognized by the coryza, possibly 
with eruption on the soft palate, the course of the temperature, and the 
exposure to specific infection. 

Black measles is the name given to malignant forms in which, owing 
to complications, particularly pneumonia, the skin is dusky and the 
eruption comes out poorly and has a bluish color. In rare instances 
the eruption shows a hemorrhagic tendency, the spots being livid or 
ecchymotic. Actual hemorrhages from mucous surfaces may occur, 
the patient dying in coma or convulsions. 



264 GENERAL DIAGNOSIS. 

Rubella. 

In a few instances this infection may run its course without fever. 
In the large majority of cases, however, a moderate degree of fever 
prevails and in some it may reach a considerable height. 

Rubella is an acute, specific, contagious, and infectious fever, char- 
acterized by a gradual onset, with moderate fever, sore-throat, and 
slight coryza. The eruption, which appears without prodromata, 
usually resembles measles more than scarlatina. The duration, how- 
ever, is shorter than measles, the disease milder, and complications are 
rare. 

The disease is amply proved not to be a hybrid of measles and 
scarlet fever. The incubation-period varies from one to three weeks, 
but is generally about two. As a rule, this period is past without 
symptoms. 

The invasion is without prodromata, or none more definite than 
languor and indisposition, the first thing noticed being the eruption. 
This in some cases consists of pale-red, smooth, slightly raised blotches, 
closely resembling measles, but more pronounced on the trunk, and 
discrete. This is probably a very rare form. More commonly it 
consists of rose-red maculae or papules, occasionally confluent, but 
usually discrete, and most marked upon the trunk. In still other 
cases the eruption closely resembles that of scarlatina, differing chiefly 
in being a paler red and accompanied by less heat of skin. Sometimes 
the eruption is circumscribed, as upon the face or limbs. It is usually 
the seat of considerable itching, and this may be the first symptom 
that attracts the patient's attention. It will be seen that the eruption 
is multiform in character. Concurrently with the eruption, there is 
usually slight rise in temperature (100°-101°), suffusion of the eyes, 
with slight lacrymation and photophobia, and slight pharyngitis ; 
nausea is not uncommon, but vomiting is very rare. Higher tempera- 
tures have been recorded in a few cases, and so have nervous symp- 
toms, such as delirium and convulsions, but they are chiefly interesting 
as very exceptional possibilities. On the other hand, the disease may 
run its course without any fever. 

The eruption extends over the body in twenty-four to thirty-six 
hours, less rapidly than in scarlatina, and pales much more quickly, 
fading on the portions of the body first attacked before reaching its 
height on the last, and being completed in three or four days. Some- 
times a branny desquamation succeeds. 

In addition to the mild coryza and eruption, the most important 
objective symptom is swelling of the cervical glands, all of them being 
sometimes swollen, especially those behind the sterno-mastoid, the 
auricle, and along the margin of the hair. This adenopathy, however, 
cannot be relied upon exclusively in the differentiation from scarlatina 
and measles. 

Rubella has few complications : bronchitis, pneumonia, and otitis 
occur rarely, and still more rarely false membrane on the throat, and 
albuminuria. The prognosis is excellent. It ends almost invariably 
in recovery, except in very feeble children. 



THE DATA OBTAINED BY OBSERVATION. 265 



Infectious Diseases with Local Symptoms. 

The following infections are characterized by local manifestations 
which are of greater diagnostic significance than the fever. These 
local manifestations must, therefore, be carefully considered in the 
diagnosis, and, as intimated, must be relied upon for recognition of the 
particular infection. The infections belong to Class I. and Class II. 
of the classification in Chapter XVII. 

Mumps. 

This infection presents marked local changes about the jaws coinci- 
dent with the rise of temperature. The infection is recognized by the 
swelling of the parotid and submaxillary glands or by the occurrence 
of orchitis. It has been described in the chapter devoted to objective 
changes of the face. 

Glandular Fever. 

Glandular fever is an infectious disorder, the cause of which has not 
been accurately determined. It is characterized by fever,, usually 
occurring abruptly, with headache, pains in the limbs and in the lymph 
glands of the neck. On examination of the fauces a slight pharyngitis 
is observed and the tonsils are enlarged. With the rise of temperature 
there is frequent nausea and vomiting. The temperature rises abruptly 
to about 102°. In the second twenty-four hours the glands of the 
neck, particularly those behind the sternocleidomastoid muscles, en- 
large. They are tender. Although there may be some slight 
oedema there is no redness or swelling of the skin. The fever contin- 
ues for three or four days ; the enlarged glands, however, may remain 
for several weeks, and may end in suppuration. 

The infection usually occurs in children between the age of five and 
eight years. It may be epidemic and occur often earlier in life than 
just mentioned. The other lymphatic glands about the neck and in 
the axilla and groin may be enlarged. In not a few instances there is 
enlargement of the spleen, and cases of enlarged liver and mesenteric 
glands are reported. The absence of an eruption serves to determine 
the infection from the eruptive fevers associated with adenitis, particu- 
larly measles and rotheln. 

Pertussis. 

The attention of the physician is called to this infection by the pecu- 
liar character of the respiratory symptoms. Fever is more notable as 
an expression of one of the complications — broncho-pneumonia — than 
of the general infection. It may, however, be a serious symptom of 
the infection. 

Whooping-cough is a specific catarrhal inflammation of the respira- 
tory passages, involving especially the trachea and bronchi, and char- 
acterized by paroxysms of cough, which are succeeded by spasmodic 
closure of the glottis and a peculiar inspiratory whoop. The disease 
occurs especially in childhood, is contagious and infectious, and is some- 



266 GENERAL DIAGNOSIS. 

times epidemic. Whooping-cough may be conveniently divided into 
three periods : 

1. The catarrhal stage. 

2. The spasmodic stage. 

3. The stage of gradual subsidence of the disease. 

First Stage. The patient appears to have an ordinary cold. The 
amount of redness of the mucous membrane of the eyes, nose, and 
throat varies considerably, but there is not much discharge from the 
mucous surfaces. The cough is dry, and sometimes a ringing quality 
can be detected. The patient is irritable, has slight fever, diminished 
or capricious appetite, and restless sleep. A mild bronchitis of the 
larger tubes can be detected by physical exploration. 

The cough gradually becomes more frequent and paroxysmal, the 
eyes are red and suffused, and there is a mucopurulent discharge from 
the nose. The face often looks slightly swollen, especially about the 
upper part and under the eyes. Lymphocytic leucocytosis is common. 

The Second Stage. Transition from the first to the second stage is 
marked by the appearance of the characteristic whoop. The parox- 
ysmal cough is made up of a series of rapid expiratory efforts, diminish- 
ing in force and duration ; when these cease there succeeds a prolonged 
crowing inspiration — the whoop. There may be only one paroxysm 
of coughing at a time, but more commonly, and always in severe cases, 
one paroxysm is succeeded by another. During the coughing the 
child's eyes become suffused, the tears overflow, and there is a discharge 
of serum or mucopus from the nose, and of saliva and bronchial secre- 
tion from the mouth. The face becomes swollen and dusky. If the 
child is walking about, it catches some object for support during the 
paroxysm ; or, if old enough, rushes for the water-closet or a basin, 
because the seizure usually terminates in vomiting. The matters 
vomited consist of tenacious mucus and the' contents of the stomach. 
With the mucus there may be streaks of blood, and occasionally there 
is pure blood. During severe paroxysms, hemorrhages are apt to 
occur ; these are generally small and most frequently submucous. In 
well-marked cases, when the disease has lasted some time, the face has 
a characteristic appearance — it is swollen, sodden, and dusky, with 
dull, heavy, red, and watery eyes. There is often ulceration of the 
lingual fraenum. 

The number of paroxysms varies from two or three to twenty or 
thirty or more in twenty-four hours, and they are worse at night. 

The whoop, while characteristic, is not present in every case, being 
absent especially in babies and very young children. Sometimes chil- 
dren have " choking spells " without much coughing and without the 
whoop. Again, when pneumonia or measles occurs as a complication, 
the whoop usually ceases for the time, but may reappear later. 

Third Stage. The third stage is less well denned than the first two. 
It may be said to begin when the nocturnal exacerbations become less 
frequent and severe. The number of paroxysms during the day dimin- 
ishes, and vomiting is a less frequent accompaniment. Appetite begins 
to improve, and the child begins to gain in flesh and to pass more 
restful nights. 



THE DATA OBTAINED BY OBSERVATION. 267 

The duration of the disease is variable. Ordinarily it lasts from six 
to eight weeks, but it may be prolonged for several months. The 
patient is liable, whenever he catches a fresh cold, to a temporary 
return of the spasmodic cough, sometimes with the whoop. 

The great majority of the cases occur before the sixth year, and most 
of these between the second and fourth years. 

Rheumatic Fever. 

Rheumatic fever is an infection associated with local symptoms of 
joint-, endo-, and pericardial inflammation. The local symptoms are so 
extreme as to call attention at once to the nature of the infection apart 
from the course of the fever, as it is largely upon these symptoms that 
the diagnosis is made. The reader is referred to Chapter XIII. , in 
which the diagnosis of rheumatic fever is discussed. 

Dengue. 

The peculiarity of the fever in this infection is that it is attended by 
severe pains in the muscles and joints. It is an acute contagious dis- 
ease, occurring in epidemics and characterized by severe pains in the 
head, back, and joints, various skin eruptions, a prolonged convales- 
cence, and a very low rate of mortality. 

The disease occurs in epidemics in tropical and subtropical countries, 
and rarely in cooler climates. It derives its name, dengue (dandy), 
from the stiff and unnatural gait assumed by convalescent patients. 
In the southern parts of the United States an expressive name given 
to the disease is " breakbone fever/' 

The specific cause of the disease is believed by Dr. McLoughlin to 
be a micrococcus which is isolated. The period of incubation is short, 
varying, however, from a few minutes to several days, or even a week. 
Invasion is very sudden and is rarely preceded by any prodromata. 
It is marked by chilliness or a chill, and very severe pains in the head, 
back, and limbs. In children the onset may be by convulsions, which 
are sometimes followed by stupor and vomiting. , The pains are some- 
times excruciating, and are accompanied by tenderness of the muscles ; 
there is extreme debility. The temperature rises to 102° or 103°, but 
rarely is much higher. 

The pulse is frequent — 110, 120, or more. In from one to three 
or five days the temperature falls to or below normal (the remission), 
accompanied by sweating or diarrhoea, and fluctuates about this level 
for several days, when a second and moderate rise in temperature, 
which is of short duration, occurs. During the first rise in tempera- 
ture there is a transient, generally scarlatiniform rash, which is not 
followed by desquamation. The urine is febrile but not albuminous. 
During the remission eruptions — scarlatiniform, herpetic, urticarial, or 
like miliaria — begin to appear, accompanied by the secondary rise in 
temperature. The eruptions may be in successive crops, and are fol- 
lowed by desquamation. Convalescence is now established, but may be 
interrupted by relapses. Strength is regained very slowly. The most 
frequent complications are disorders of the nervous system, but bron- 
chitis and diarrhoea occasionally occur. 



268 GENERAL DIAGNOSIS. 

Beri-beri. 

Beri-beri is a febrile infectious disorder which prevails in epidemic 
form, limited to tropical and subtropical countries. It is characterized 
by multiple neuritis associated with anasarca. By most observers it is 
believed to be an acute infection, although not a few think it is an 
intoxication due to certain kinds of food. This is the view which pre- 
vails in Japan. The circumstances predisposing to infections generally 
prevail, however, such as overcrowding, the prevalence in hot and 
moist seasons, and the exposure of the patient to climatic influence. 
It is far more common in men, and usually attacks subjects whose ages 
range from sixteen to twenty-five. 

Several clinical forms are seen. In the most complete form there is 
rapid loss of power in the legs and arms, with atrophy of the muscles. 
The patients complain of pain, and later oedematous symptoms may 
appear. With the loss of poAver in the legs there is paresthesia, with 
frequent palpitation of the heart and dyspnoea. The pain in the mus- 
cles is associated with weakness and tenderness. In milder degrees of 
this form, pain, weakness in the legs, diminishing of the sensibility, 
and paresthesia are the most common symptoms. Their onset will 
be gradual and be accompanied by catarrhal symptoms. The symp- 
toms may recur from time to time, and are much more aggravated 
during the warm season. Its recurrence and incomplete form may 
continue ten or fifteen years. 

Following the pain and weakness of the muscles, in some cases 
oedema becomes very pronounced, associated with effusions into the 
serous cavities. General anasarca is attended by palpitation and rapid 
action of the heart and dyspnoea. In this so-called wet or dropsical 
form atrophy of the muscles is not observed until the oedema disap- 
pears. In some instances the infection is very intense, and is charac- 
terized by more marked cardiac symptoms. In these instances acute 
dilatation may be followed by cardiac paralysis and death in twenty- 
four or forty-eight hours. 

The diagnosis is based upon the occurrence epidemically or endemi- 
cally in tropical regions of peripheral neuritis with oedema. Thus far 
no bacteriological diagnosis obtains. 

Constitutional Syphilis. 

Intermittent, remittent, or continuous fever is attendant upon this 
infection sometime during its course. (See Afebrile Infections, Chap- 
ter XVI.) Want of recognition of the cause of this febrile phenomena 
leads to many mistakes in diagnosis. (See Fig. 63.) 

Constitutional syphilis may be acquired or congenital. 

Acquired syphilis is characterized, first, by the initial lesion, or 
chancre, which appears usually in a week after contagion ; second, by 
a 'period of incubation generally lasting six weeks, but varying from 
one to three months ; third, by so-called secondary symptoms, com- 
prising febrile symptoms, polymorphous skin-eruptions, ulcers upon 
the tonsils, adenitis, less frequently mucous patches in the mouth, or 
condylomata about the anus, iritis and retinitis, and loss of hair. The 
lesions of this period are symmetrical. Fourth, after an interval vary- 






THE DATA OBTAINED BY OBSERVATION. 269 

ing from several months to twenty years, by so-called tertiary phenom- 
ena, which manifest themselves in some cases. These are clue to chronic 
inflammatory indurations of the skin and subcutaneous tissue, resulting 
in suppuration and ulceration ; or of the bones, producing periostitis 
and necrosis ; or of organs, producing gummata and cirrhosis ; or of 
the nervous system, resulting in gummata or chronic degenerative 
changes. The lesions of this period are unsymmetrical. 1 

The course of syphilis in different persons varies as widely as any 
of the eruptive fevers. In some the chancre is a mere papule which 
heals almost unnoticed ; no secondary symptoms appear, and tertiary 
symptoms also are altogether wanting, or a chronic degeneration of 
the nervous system develops after the lapse of many years, the patient 
in the meantime remaining in apparent health. All this may occur, 
too, without the aid of specific treatment. In other cases the disease 
is malignant ; tertiary symptoms appear very early or appear to take 
the place of secondary symptoms ; ulceration may rapidly melt down 
and destroy the alse of the nose or the soft palate ; or rebellious perios- 
titis with necrosis may attack the tibia?, the nasal bones, or the cranium. 

In an ordinary case of acquired syphilis, in about six weeks after 
the appearance of the chancre, the patient complains of languor, weari- 
ness, slight fever, pains in the bones, impaired digestion, and a ten- 
dency to anaemia. An eruption now appears. It is most marked on 
the trunk and upper extremities, especially the chest and forehead 
(corona Veneris). The eruption may be roseolous, squamous, vesico- 
papular, papular, pustular, bullous, or tubercular. The color has been 
aptly compared to that of a slice of raw ham. The enlargement of the 
inguinal, epitrochlear, and postcervical glands, which precedes the 
eruption, persists. Shallow ulcers with a sharply defined grayish out- 
line appear on both tonsils. They are painless and do not spread. 
Ulcers are also liable to appear upon the pharynx, buccal surfaces, 
tongue, angles of the mouth, penis, vulva, vagina, and around the 
anus. In the mouth these are apt to be very painful, and may persist 
in spite of treatment for weeks or months. Relapses are not uncom- 
mon. Sometimes there are raised white patches upon the pharynx. 
Sometimes the hair becomes very thin and falls out, leaving the patient 
Avithout eyebrows and more or less bald. Iritis and retinitis are usually 
later symptoms. Other symptoms occasionally occurring at this stage 
are periostitis, usually slight, and onychia. 

The most common of the symptoms enumerated are the eruption and 
the tonsillar ulceration. 

The eruption comes out gradually during two or three weeks, and 
persists for about two months. Rarely, however, it is fleeting, or, on 
the other hand, is unduly prolonged. 

The secondary symptoms last from six to eighteen months. After 
their disappearance the patient may remain entirely well for life. In 
other cases after apparent health, lasting for months or years, the 
tertiary phenomena already mentioned appear. In the interval the 
patient may have suffered with various local skin eruptions or with 
ulcers upon the buccal mucous membrane. 

1 Fever is a constant accompaniment of all forms of syphilis. (See Fever. ) 



270 GENERAL DIAGNOSIS. . 

The tertiary lesions of syphilis are the late syphilides (see Skin) and 
gummata of the skin, subcutaneous connective tissue, muscles or inter- 
nal organs. Visceral syphilis is seen at this stage. In the brain and. 
spinal cord gummatous tumors, gummatous meningitis, gummatous 
arteritis, and localized scleroses are found. The symptoms are those 
of brain tumor when the cerebrum is affected, and of tumor, menin- 
gitis, or sclerosis when the cord is affected. In syphilis of the lung 
we may find gummata scattered through the lung or a fibrous inter- 
stitial pneumonia beginning at the root of the lung. Diffuse syphilitic 
hepatitis or gummata may be found when the liver is affected. The 
rectum is the most common seat of syphilis of the digestive tract. 
Myocarditis and localized gummata and endarteritis occur in cardiac 
syphilis, while in vascular syphilis obliterating endarteritis and gum- 
matous periarteritis are found. Syphilitic orchitis often occurs. Its 
presence may aid in the diagnosis of obscure visceral syphilis. 

Hereditary syphilis differs in some respects from the acquired form. 
At birth the syphilitic infant usually exhibits no evidence of its inher- 
ited taint. In the course of from one to twelve Aveeks it develops a 
catarrhal inflammation of the nasal mucous membrane, which causes 
snuffling in breathing, and hence is called " snuffles." An eruption 
soon appears, symmetrical in distribution. It is most frequently ery- 
thematous or papular, but it may be squamous, vesicular, pustular, or 
bullous. In hereditary syphilis it is more apt to be moist and to favor 
the genitalia and flexures of the thigh than in acquired syphilis. It is 
of the same ham-color as in acquired syphilis. Coincident with the 
" snuffles " and eruption appear stomatitis and ulcers at the angles of 
the mouth, and sometimes condylomata around the anus. Meantime 
the child has begun to waste, to be peevish, to be ansemic, and gradu- 
ally to assume the appearance of a wizened, dried-up old man. As in 
acquired syphilis, there may be iritis, though it is uncommon, and 
inflammation of the other structures of the eye, but nodes and disease 
of the liver are rare. The infant very frequently dies during this 
period from exhaustion and inanition. 

If the child survives for a year the secondary symptoms usually 
disappear and the disease becomes latent. Relapses may occur, and 
in them, according to Mr. Hutchinson, condylomata are likely to 
appear. The same observer states that the tertiary period may begin 
at any time after the fifth year, but it is commonly delayed till about 
the period of puberty. In the meantime the patient may appear fairly 
well, but usually his development is retarded, there is a tendency to 
amemia, and he has often nasopharyngeal catarrh, flattening of the 
bridge of the nose, premature decay of the upper incisor teeth, and 
] > r< >t i iberant forehead. 

The teeth may be perfectly normal, in other cases characteristically 
syphilitic. The malformation affects especially the upper central in- 
cisors of the permanent set. It was first described by Mr. Hutchin- 
son. It " consists in a dwarfing of the tooth, which is usually both 
narrow and short, and in the atrophy of its middle lobe. This atro- 
phy leaves a single broad notch (vertical) in the edge of the tooth, and 
sometimes from this notch a shallow furrow passes upward in both 
anterior and posterior surfaces nearly to the gum. This notching is 



THE DATA OBTAINED BY OBSERVATION. 



271 



usually symmetrical. It may vary much in degree in different cases ; 
sometimes the teeth diverge, and at others they slant toward each 
other." (See Part II., Chapter IV.) 

Further, the patient may have had or may now be attacked with 
keratitis, affecting both eyes, producing cloudy opacities and accom- 
panied by great photophobia. Again, there may be nodes upon the 
long bones, with nocturnal exacerbations of pain. Cerebral deafness, 
according to Hutchinson, is not rare, but cerebral blindness is. There 
may be ulceration upon the legs, and periostitis and necrosis. The 
patient usually recovers completely, but he is more liable to be carried 
off by intercurrent disease than a healthy person, and in general has 
less resisting power, especially to tuberculosis. 

Diagnosis. The diagnosis of hereditary syphilis is based upon the 
occurrence of snuffles and skin eruptions, and the existence of keratitis 
or of cicatrices, especially about the angles of the mouth. A history 
of repeated miscarriages is suggestive of maternal syphilis. The diag- 
nosis of acquired syphilis is based upon the history of chancre, when that 
history is obtainable ; upon the existence of polymorphous eruptions, 
or of non-traumatic ulcers upon the legs of young adults, or of scars 
in the groins or over the tibia, or of nodes, or of alopecia associated 
with sore-throat or mucous patches. The presence of obscure disease 
of the bones, glands, or spinal cord should lead to the search for a' 
possible syphilitic infection. (See Malaria, Chapter XIX.) 



Fig. 



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X = MERCURIAL INUNCTION 

Reduction of heemoglobin after mercurial inunction in syphilis. 

Examination of the blood during mercurial treatment may, in accord- 
ance with Justus' observations, show the presence of syphilis. If this 
disease is present the percentage of haemoglobin falls suddenly and 
rapidly during the hours immediately following the first administration 
of the drug. Cabot has confirmed his observations. The accompany- 
ing chart shows the effect of mercury upon the blood. (See Fig. 56.) 

Weil's Disease. 

The occurrence of jaundice without local hepatic symptoms during 
the course of fever suggests an infectious process. It is a well known 
symptom of pysemia and septicaemia. In the following infection 
fever and jaundice are coordinate symptoms. Acute febrile jaun- 
dice, which rapidly becomes malignant, occurring in butchers, laborers, 



272 GENERAL DIAGNOSIS. 

and brewers, has been described by Weil. After exposure to cold 
generally, as in a beer-vault, the patient is seized with a chill, fol- 
lowed by fever, with headache, vomiting, and epigastric pain. Jaun- 
dice sets in rapidly. The temperature remains high, or may be inter- 
mitting. Stupor, delirium, and coma, albuminuria, with suppression of 
urine, subcutaneous hemorrhages, and hemorrhages from mucous mem- 
branes, rapidly ensue. Black vomit occurs early. In one of my cases 
there was enlargement of the liver, with subcutaneous oedema over the 
hepatic area. The microscopical appearances were those of acute dif- 
fused parenchymatous inflammation. In another, a brewery man, the 
liver was enlarged, but without unusual change, save congestion. 

The delirium is sometimes violent. The appearance and symptoms 
suggest acute yellow atrophy of the liver. The etiological distinctions 
are noteworthy : the liver is not small ; leucin and ty rosin are not 
found in the urine ; the jaundice is more intense. The diagnostic cir- 
cumstances of epidemic and contagious diseases serve to exclude yellow 
fever. (See Yellow Fever.) 

Miliary Fever. 

The occurrence of fever in association with profuse sweating is rarely 
seen without attendant signs of pyogenic infection. When several cases 
with these symptoms occur at the same time, suggesting an epidemic, 
the infection we are about to consider must be thought of. 

Miliary fever, or sweating-sickness, is an infectious disease, occur- 
ring in epidemics, and characterized by moderate fever, profuse sweat- 
ing, tenderness and a sense of oppression at the epigastrium, and a 
vesicular eruption. The disease has occurred epidemically in Eng- 
land, but is not met with now outside of France and Italy. 

After mild prodromal symptoms the disease sets in suddenly with 
moderate fever, profuse sweating, and epigastric distress, sometimes 
amounting to anguish. The characteristic eruption appears on the third 
or fourth day. It consists first of small reddish maculae, in the centre 
of which a vesicle develops. The latter varies in size from a pinhead 
to a pea. The contents are at first clear, but subsequently become 
purulent. Desiccation and desquamation follow. The eruption is 
most profuse generally upon the neck and trunk. Sometimes there 
are marked nervous symptoms, and even convulsions and fatal collapse. 

It is distinguished from rheumatism by the moderate fever and 
absence of joint-swellings, and from malarial fever by the absence of 
chills, of periodicity in the febrile movement, and absence of malarial 
organisms from the blood. 

The duration of the disease is from one to four weeks. The mor- 
tality in some epidemics has been very high, in others very low. 

Infections Transmitted from Animals to Man. 

When fever occurs in persons in contact with animals or their prod- 
ucts the possible occurrence of the infections — milk-sickness, foot-and- 
mouth-disease, and rabies, as well as glanders and anthrax — must be 
thought of. The infections which follow are of uncertain bacteriology, 
and are recognized not alone by the fever but also by the local symp- 
toms and a history of infection. 






THE DATA OBTAINED BY OBSERVATION. 273 

Milk-sickness. 

It is an acute disease affecting cattle, and transmitted from them to 
human beings in the milk or meat. The disease is limited to a few 
sparsely settled localities west of the Allegheny Mountains. It is char- 
acterized by great debility, with muscular tremor upon motion (hence 
the name " trembles "), vomiting (hence called " puking fever "), a 
peculiar foetor of the breath, obstinate constipation, and moderate fever 
or subnormal temperature. The vomited matters are said to be of a 
peculiar soapy material of yellowish or greenish color. The duration 
is usually less than a week. The patient may sink into a typhoid con- 
dition and die in coma, or he may die in a few hours. Convalescence 
is protracted. 

Foot-and-mouth Disease. 

A specific, infectious disease, communicated to man through cattle, 
sheep, or pigs, and characterized by a stomatitis. It is communicable 
by milk ; the period of incubation is from three to five days. Inva- 
sion is characterized by slight fever, heat, and soreness of the mouth, 
and the development of vesicles, which burst and leave shallow ulcers. 
Saliva is freely poured out. The tongue swells greatly, and eating is 
painful. Vesicles sometimes appear about the fingers, but not upon 
the feet. The disease lasts from one to two weeks, and ends almost 
invariably in recovery. 

Hydrophobia. 

An acute, specific disease communicated to human beings by the 
bites of animals similarly affected. The animals most frequently 
affected are the dog, fox, wolf, cat, and skunk ; 90 per cent, of the 
cases in human beings are due to dog-bites. 

The period of incubation is uncommonly long and very variable — from 
two weeks to two months usually. It is said in some cases to be a 
year or more. The disease has been divided into three stages — the 
melancholic, the spasmodic, and the paralytic. 

In the melancholic stage there is pain, hyperesthesia, or even reopen- 
ing of the healed wound. The patient is extremely depressed in spirits, 
and may be irritable. He seems to be laboring under a constant ten- 
sion of fear, and is keenly sensitive to light, sounds, or draughts. He 
is affected with thirst, but attempts to swallow water cause intensely 
painful spasm of the larynx. 

The second stage is reached usually on the second day. The laryn- 
geal spasms are increased and lead to intense dyspnoea and to pitiable 
struggling and gasping on the part of the patient. In addition to the 
convulsive seizures, the patient foams and froths at the mouth, and his 
face expresses the extreme terror and mental anguish he feels. The 
second stage lasts from one to three days, and is followed by the third 
stage, exhaustion intermitting with paroxysms of less severity. The 
patient may now be able to swallow easily, but there is great weakness 
of the heart, and death may occur from failure of the heart, from 
asphyxia, or in a convulsion. The duration, as indicated, is only a few 
days. The result is practically always fatal, but recovery may be 
possible. Bites of the face are the most likely to be fatal. 

18 



CHAPTER XIX. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 

FEVER. THE INFECTIOUS DISEASES. 

Infections Recognized by Examination of the Blood. 

Microscopical Examination. The following infections are recog- 
nized by the examination of fresh blood : Relapsing fever, malaria, 
yellow fever, anthrax. Typhoid fever is also recognized, but is more 
frequently diagnosticated by means of serum diagnosis and by culture 
methods. By staining cover-slip preparations of the blood the diagnosis 
by the direct method is confirmed. 

Serum diagnosis enables us to determine the presence of typhoid 
fever, yellow fever, and Malta fever. 

Bacteriological examination of the blood corroborates the diag- 
nosis of typhoid fever made by the above methods. By it we are also 
enabled to determine the presence of gonorrheal infection, of cerebro- 
spinal meningitis, of the pneumococcus infection, and, in many in- 
stances, of infection due to the staphylococcus, streptococcus, and bacil- 
lus coli communis. The gonococcus infection alone will be considered. 
It must be remembered that the micro-organisms cannot be found in 
the blood mitil late in the course of the disease, and even then the 
infection must have a certain degree of intensity. Unfortunately, they 
cannot be demonstrated in the majority of cases. Positive cultures 
for the above reasons are very valuable. ^Negative cultures do not 
exclude septic infections. 

Relapsing Fever. 

Relapsing fever is the first infection which we will consider, because 
historically it is the most important. It is the first infection in which 
a micro-organism was found to be causal, and is one to which Koch's 
laws can be applied. It is an acute, infectious, and contagious fever, 
occurring in epidemics, and characterized by the sudden onset of a 
febrile period lasting five or seven days, which is followed by an inter- 
mission lasting usually a week, and this in turn by a relapse lasting 
three days. Its development is favored by filth and famine, but the 
specific cause is believed to be the spirillum of Obermeier, which is 
constantly present in the blood during the febrile stage. 

The stage of incubation lasts from five to eight days (Pepper), during 
which the patient may complain of malaise, lassitude, and flying pains. 
The invasion is sudden. It manifests itself by a chill or chills, frontal 
headache, pains in the back and limbs, vertigo, and great physical 
weakness. The temperature rises very rapidly, reaching 105°, 106°, 



THE DATA OBTAINED BY OBSERVATION. 275 

or even higher, in the first day or two. The face is flushed, epistaxis 
sometimes occurs, the headache and other pains persist, but delirium 
is not common. The appetite is usually lost, thirst intense, the tongue 
coated white but moist, the bowels constipated. A mild catarrhal jaun- 
dice is not infrequent. Pepper states that nausea and vomiting are 
prominent symptoms, the matters vomited at times containing blood. 
Tenderness with pain in the epigastrium is frequently complained of. 

The urine is scanty, high-colored, and frequently contains albumin 
and casts ; when jaundice exists the urine contains bile-pigment and 
sometimes blood. 

There is no peculiar eruption in relapsing fever, but in this, as in 
other fevers, erythemata, petechia?, and sudamina may be present. 

The pulse is often very frequent and soft, and haemic murmurs may 
be audible. 

The objective symptoms are few. They consist of the flushed face, 
sometimes with slight jaundice and epistaxis, tenderness in the epigas- 
trium, with moderate enlargement of the spleen and liver, and consid- 
erable cutaneous hyperesthesia, with tenderness along the nerve-trunks. 

Bronchitis and sometimes hypostatic congestion of the lungs, with 
their usual physical signs, may be present. 

These symptoms continue without much change until the fifth or 
seventh day, when a decided crisis occurs. Sometimes this is deferred 
until the tenth day. The temperature within twelve hours falls from 
106° or 108° to or below normal ; the pulse diminishes in frequency 
from 120 or 130 to 60 or 70 ; vertigo, headache, and other pains dis- 
appear as by magic. The crisis is marked most frequently by a pro- 
fuse sweat, sometimes by diarrhoea, epistaxis, metrorrhagia, or intesti- 
nal hemorrhage. The patient now enters upon convalescence without 
fever, and apparently makes rapid strides toward complete recovery. 
On the seventh day from the crisis, however, a sudden relapse occurs, 
with a repetition of the symptoms of the first attack. The temperature 
may be higher and the febrile symptoms more severe, but the duration 
is shorter — only three or four days. The spirilla, which disappeared 
in the apyretic interval, are again found in abundance. A second 
crisis, with its associated symptoms, now occurs. The spirilla again 
disappear, and in the majority of the cases there is no further bar to 
complete recovery. A second, third, and even a seventh relapse may 
occur, as in a case reported by Pepper. Organic lesions are not usually 
left behind, unless they have occurred as complications ; but even in 
ordinary cases the patient is left w r eak, anaemic, and with poor circulation. 

Examination of the Blood. Microscopical Examination. In 
the blood at the height of the disease the spirillum of Obermeier is 
found. 

These are slender, Avavy, thread-like organisms of spiral shape, seven 
or eight times the length of a red blood-cell, with a very lively forward 
movement in the direction of the long axis. They are from 16 to 40// 
by 0.1/i. Under a low power the blood may appear to be in motion, as 
the result of their movement. They have so far been found only in the 
height of the febrile attacks ; but Von Jaksch states that as long as a 
relapse is to be feared the blood contains peculiar, highly refracting bodies 



276 GENERAL DIAGNOSIS. 

resembling diplococci, which are especially numerous before the attack • 
in some cases it has seemed to him that these diplococci at the very 
beginning of an attack develop into short, thick rods, from which the 
spirilla develop ; they may, therefore, prove to be spores. Staining is 
unnecessary for the detection of spirilla, but cover-glass preparations of 
the blood can, if desired, be stained with fuchsin or gentian-violet or 
Loftier' s methylene-blue. (Plate III., Fig. 4, A.) 

Serum Diagnosis. It sometimes happens that a diagnosis should 
be made during the afebrile period when the organisms have disap- 
peared entirely from the peripheral circulation. LowenthaFs method 
is as follows : A drop of the suspected blood is mixed with one con- 
taining the living micro-organisms. The mixture is sealed up with 
wax between slide and cover-glass and left in the thermostat at 37° 
for half an hour. Blood from a patient who has just had a paroxysm 
will destroy the spirilla, so that they lose their motility and spiral curl 
and accumulate in bunches. The reaction is like that of Pfeiffer's 
phenomena rather than agglutinative. It is to be remembered that 
the bactericidal power of the blood dies out before the next paroxsym. 

Inoculation. As further aid to diagnosis typical relapsing fever 
can be produced by injecting the infected blood into monkeys. 

The most frequent complications are on the side of the lungs, kid- 
neys, and heart. Lobar pneumonia is the most frequent. The heart 
becomes weakened by the very high fever and thrombosis, or sudden 
failure results. Embolism is very frequent. Suppurative parotitis, 
abscess of the spleen, profuse epistaxis, abortion in pregnant women, 
and neuritis deserve mention. 

Relapsing fever occurs at all ages, but is most common in adults. 

The duration varies according to the number of paroxysms. If 
there is only one, it is about eighteen days. Under the name " bilious 
typhoid " a malignant form of relapsing fever has been described. It is 
characterized by intensity of the symptoms of the ordinary form, and 
by bilious or bloody vomiting, jaundice, and delirium, or by collapse, 
with purple nose, a small, frequent weak pulse, rigidity of the abdomi- 
nal muscles, tenderness in the epigastrium, and cold, clammy skin. In 
some of the cases described by Graves, intussusception of the intestines 
was found after death. In other cases uraemia is an active factor. 

Diagnosis. The earlier cases in an epidemic may not be recognized, 
unless the blood be examined, until the occurrence of the characteristic 
relapse. The diagnosis is based upon the occurrence of an epidemic, 
the presence of the predisposing factors, the clinical course, and the 
examination of the blood. It is most likely to be mistaken for typhus 
fever, which occurs under similar conditions. The aspect of the two 
diseases is very different. In typhus there is a heavy, stupid, some- 
times besotted expression, with slight redness of the eyes and a con- 
tracted pupil. The patient lies oblivious of his surroundings, with 
low muttering delirium and ataxic symptoms. In relapsing fever, on 
the other hand, the sensorium is rarely much disturbed, the spleen and 
liver are enlarged, and there is hyperesthesia. Moreover, in typhus 
there is a spotted eruption, later becoming petechial. In relapsing 
fever this is absent. 



THE DA TA OB TA IN ED B Y OBSEB VA TION. 277 

Anthrax. 

The next infectious disease, the cause of which can be determined by 
an examination of the blood, is anthrax. This affection is also of his- 
torical importance, and is probably the best worked out of any of the 
infections common to man and the lower animals. It is also called 
malignant, pustule, charbon, wool-sorter's disease, splenic fever. It is 
derived principally from herbivorous animals, and characterized by the 
development of a pustule or boil, with extensive brawny oedema and 
subsequent toxaemia ; or toxaemia may appear first and metastatic 
abscesses subsequently. The disease also attacks the gastro-intestinal 
mucous membrane and the lungs. 

Anthrax is caused by the anthrax-bacillus and its toxins. Outside 
of the body it forms endogenous spores, which are extremely tenacious 
of life, and to which infection is invariably due. They infect not only 
the carcasses of animals, but also the soil, all utensils used in the care 
of the animals or the soil, and they persist with infective power in the 
hides, hair, hoofs, and wool (" wool-sorter's disease "). It is possible 
that it may be transmitted to man by stings of insects, particularly 
flies and mosquitoes. 

The period of incubation varies from a few hours to several days. 
In the form known as malignant pustule the patient has a pricking or 
burning feeling, which may lead him to think he has been stung by 
an insect at some exposed part of the body, particularly the hand, face, 
or neck. At the seat of irritation, first a papule, then a vesicle, de- 
velops. The vesicle may attain considerable size. The contained 
fluid quickly passes from clear to bloody, and then escapes, leaving a 
dark-brown or black scab (anthrax). 

The original vesicle may be surrounded by a series of smaller ones. 
Instead of disappearing, the base of the vesicle becomes inflamed and 
indurated, the induration extending to surrounding tissue and causing 
a condition of brawny oedema. A whole arm or one side of the face 
and neck may be swollen. There may or may not be an associated 
lymphangitis and adenitis. 

The general health does not suffer at first, but in a day or two fever 
sets in, accompanied by delirium, sweating, great weakness, enlarge- 
ment of the spleen, severe pains in the limbs, and diarrhoea. Death, 
preceded by collapse, may occur in from five to eight days (Fagge), 
or the tissue occupied by the pustule may slough out. 

Bollinger and others have called attention to anthrax oedema, in 
which there is no pustule, but only a yellowish or greenish swelling of 
the tissues. Gangrene may ensue. It is seen most frequently in the 
eyelids, but may be on the head, hand, or arm. 

Intestinal Form. Anthrax of the gastro-intestinal mucous mem- 
brane, as described by Bollinger, presents the following symptoms : 
the patient first complains of malaise, loss of appetite, pains in the 
limbs, giddiness, and headache. Then vomiting may set in, and a 
more or less severe diarrhoea, the evacuations often containing blood. 
There may be pain in the abdomen, which becomes somewhat tumid ; 
the spleen is enlarged. Dyspnoea and lividity appear, with restlessness 



278 GENERAL DIAGNOSIS. 

and with excitement or stupor. Epileptiform convulsions may occur, 
the upper limbs may be affected with tetanic spasms, there may be opis- 
thotonos, and the pupils may be widely dilated. The pyrexia is slight, 
and death is preceded by extreme collapse. The duration of the disease 
is usually from two to seven days, but sometimes it is scarcely twenty- 
four hours. 

Wool-sorter's Disease. Still another form of anthrax occurs among 
the wool-sorters of Bradford, England ; it is characterized by intense 
dyspnoea and a feeling of oppression or constriction. Breathing is 
labored, but not much accelerated. Only a few coarse rales are to be 
heard on auscultation. The expectoration may be abundant and 
bloody, or absent. There is a tendency to collapse, with cold, bluish 
skin, and a subnormal axillary temperature. The rectal temperature, 
however, is raised two or three degrees. Death may occur in coma 
and convulsions, or suddenly, the mind being clear. The duration of 
the disease is from one to five days. Dr. Bell says that those who 
survive for a week generally recover. 

Examination of Blood. The bacillus anthracis is found in 
the blood of the patient or the pus of the lesions of anthrax or malig- 
nant pustule. 

Morphology. A bacillus, 2 to 3/* up to 20 to 25// in length and 
1 to lj/z in breadth. The bacilli are often joined end to end in long 
threads, and these threads are massed together in bundles. As found 
in animals they are short rods with square ends. They stain best with 
Loftier' s blue, but also with the basic anilines and by Gram's method. 
When in the stage of spore-formation the threads look like strings of 
beads. 

Fig. 57. 




f \ 



Bacillus anthraeis highly magnified, to show swellings and concavities at 
extremities of the single cells. (Abbott.) 

Cultures. Biological Properties. It is aerobic, non-motile, 
and liquefies gelatin. (See Plate III., Fig. 2, A ; Plate VI. ; Fig. 57.) 

It grows best in neutral or slightly alkaline media (gelatin, agar, 
milk, meat-infusion, etc.) at 20° to 38° C. The growth-limits are 12° 
and 45° C. 

Cultures on agar are quite characteristic, consisting of a dense cen- 
tral mass with twisting and crossing bundles all around it. In gelatin 
stab-cultures a fine branching threadwork grows out alongside the 
puncture. The gelatin soon liquefies and the bacilli settle in white 
masses. The growth is abundant on potato, and is grayish, dry, 
rough, and irregular. The virulence is attenuated by cultivation. 
Drying does not kill the spores. Very toxic substances are found in 
the culture-medium. 



PLATE VI 



FIG. 1. 






Anthrax-bacilli from Rabbit's Spleen. 

(Oc. 4, ob. y 1 ^ immersion.) Drawn by J. D. Z. Chase. 



Protozoa of Malaria, Intracellular and Creseemic Forms. 

(Oc. 4, ob. i 1 ., immersion. I Drawn by J. D. Z. Chase. 



THE DATA OBTAINED BY OBSERVATION. 279 

Inoculation. When inoculated, the organism produces the pus- 
tule of anthrax. If inoculated into the abdominal wall of a guinea- 
pig or rabbit death follows in forty-eight hours. No reaction is seen 
at the point of inoculation, but beyond this the tissues are oedematous. 
Ecchymoses are seen, and the underlying muscles are pale. The 
spleen is enlarged, dark in color, and soft. Cover-slip preparations 
confirm the diagnosis. 

Anthrax bacilli are not so numerous in human blood as in that of 
the lower animals. They are most likely to be found in the spleen, 
which is apt to be much swollen. 




Bacillus anthracis in the blood of* a guinea-pig. X 1040. (Gibbes.) 

Diagnosis. In doubtful cases a mouse or guinea-pig should be 
inoculated with the blood. Carbuncle is distinguished by its tendency 
to develop upon the back or shoulders and other covered portions ; 
anthrax on uncovered portions. In carbuncle there is a series of open- 
ings resembling a sieve, filled with pus and plugs of necrotic tissue. 
In anthrax there is at first a central black crust. The boggy feeling 
of carbuncle is different from that of the brawny oedema of anthrax. 
Finally, in carbuncle, anthrax-bacilli are not found in the blood. 

The intestinal and thoracic forms are distinguished by the occupa- 
tion of the patients, the absence of other adequate cause, and the result 
of the blood-examination, cultures, and inoculation experiments. 

Malarial Fevers. 

The next infection which we are about to consider is one of the most 
common the world over. In its various forms it is recognized by direct 
examination of the blood. Its clinical features are such that often but 
little difficulty surrounds its recognition, but no case should be unqual- 
ifiedly pronounced malaria without an examination of the blood. It 
comprises a group of fevers associated with the protozoan organism of 
Laveran, and is characterized by periodic paroxysms of chill, fever, and 
sweat. They are not contagious, but can be transmitted by inoculation. 

Malarial fevers, while most prevalent in tropical and subtropical 



280 GENERAL DIAGNOSIS. 

regions, are found also throughout the temperate zone, especially in 
autumn and spring. In Europe their favorite habitat is Italy, and in 
the United States the Southern and Southwestern States. Conditions 
that especially favor their development are marshes and swamps, fed 
partly by sea-water ; low ground along streams of slow current, and 
freshly upturned soil. The poison is carried in the air. 

The specific poison in malarial fevers is no doubt organic. The 
protozoan organism described by Laveran exhibits several different 
forms, which he regards as stages in the development of one organism, 
but which may be different species. Golgi maintains that there are 
several distinct varieties of parasites whose periodicity in development 
and spor ulation corresponds with the different types of fevers. 

Intermittent Fever. This is a type of malarial fever in which the 
temperature remains normal between the paroxysms. 

A malarial paroxysm is characterized by (1) chill, (2) fever, and (3) 
sweating, occurring in the order named and in immediate succession. 
The time between the beginning of one paroxysm and the beginning of 
the next is called the " interval," that between the conclusion of a par- 
oxysm and the beginning of the next the u intermission." The interval 
varies in different forms of intermittent fever : in the quotidian there 
is a paroxysm every day, with an interval of twenty-four hours ; in the 
tertian there is a paroxysm on alternate days, with an interval of forty- 
eight hours ; in the quartan there is a paroxysm every third day, with 
an interval of seventy-two hours. In double quotidian there are two 
paroxysms in the twenty-four hours, but not of the same intensity. 

In the double tertian there is a paroxysm every day, the first and 
third and second and fourth corresponding as to hour and intensity. 
That is to say, if there be a paroxysm at 10 a.m. Monday there will 
be another severe paroxysm at 10 a.m. Wednesday, while on Tuesday 
and Thursday there will be milder paroxysms, but at another hour 
than 10 a.m. 

In the double quartan severe and mild paroxysms succeed each other 
every other day, but each third day is free from any paroxysm. 

While the rule is for malarial fevers to occur periodically at the same 
hour, the second paroxysm may occur an hour or two earlier (anticipa- 
tion) if the disease is growing worse, or an hour or two later (postpone- 
ment) if it is growing better. (See Figs. 30, 31, 32.) 

Quotidian intermittents are slightly more common than tertian, while 
the quartan variety is rare. 

The incubation-period probably varies widely, depending upon the 
intensity of the poison. As a rule, repeated exposure is necessary to 
develop the disease in temperate climates. During this period the 
patient may suffer with headache, drowsiness, pains and aching in the 
limbs and back, constipation, a coated tongue, and thirst. 

The onset of a typical malarial paroxysm is marked by chilly sensa- 
tions, especially along the spine, accompanied by yawning and the 
development of " goose-flesh." Then a decided chill sets in, the patient 
shaking violently. The face is pale and pinched, the lips blue, the 
nose pointed ; as the chill becomes worse the teeth chatter, the whole 
body feels cold, the skin feeling rough, dry, cold, and harsh. The 



THE DATA OBTAINED BY OBSERVATION. 



281 



finger-nails and toe-nails are blue, the skin being wrinkled upon the 
palmar and plantar surfaces. The superficial bloodvessels are so con- 
tracted that a drop of blood is obtained with difficulty . The voice is 
thin and weak, almost inaudible. 

The volume of blood driven from the surface leads to congestion of 
the viscera, particularly the spleen, liver, and stomach. Nausea and 
vomiting are not uncommon. The spleen is perceptibly enlarged, and 
frequently the liver also. 

Although the surface temperature is depressed, the internal tempera- 
ture is rising, and may be two or three degrees above normal. By 
degrees the severity of the chill abates and the patient asks to have 
the extra bedclothing removed. Reaction has set in. The surface- 
bloodvessels dilate and the skin becomes flushed. The temperature 
continues to rise, often reaching 103° to 106°, pulse and respiration 
increasing correspondingly in frequency. The patient complains of a 
throbbing, dizzy headache, and vomiting may recur. The bowels 
remain constipated. The temperature now begins to fall, and the 
sweating-stage succeeds. Perspiration appears first upon the forehead, 
face, and neck, and gradually extends over the rest of the body. The 
perspiration becomes more and more profuse, until the whole body is 
drenched with it. All the subjective symptoms vanish with wonder- 



FiG. 59. 



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Intermittent fever. Temperature every six hours. Morning and evening temperature 
and highest at chill. 



ful rapidity, and the patient, with the exception of exhaustion, seems 
to be restored to complete health. The hot stage lasts from one to two 



282 



GENERAL DIAGNOSIS. 



hours, the cold stage from three to eight hours, and the sweating-stage 
from two to six hours. 

In the interval between paroxysms the patient is free from fever, 
but is anaemic, weak, and has impaired appetite and constipation. 
During the entire paroxysm the mind remains clear. 

The chief objective symptom, apart from the phenomena of chill, fever, 
and sweat alreadv described, is the occurrence of plasmodia in the 
blood. (See Plate VI., Fig. 2 ; and Fig. 61.) 

Examination of the Blood. The plasmodia of malaria were first 
pointed out b) r Laveran. They have been studied in Italy, especially 
by Marchiafava and Golgi, and in this country by Councilman, Osier, 
and Dock. Minute amoeboid bodies are found in the red corpuscles. 
These become pigmented with altered haemoglobin, and grow until 
they fill nearly the whole of the cell, the pigment being arranged 
chiefly in a peripheral ring. Later, the amoeboid bodies become spheri- 
cal and transparent, the pigment collecting in the centre. Sporulation 
now begins and a fresh crop of small, rounded parasites appears, to 
begin the same cycle over again in fresh corpuscles. (Plate VI., 
Fig. 2.) 

Three forms of parasites are described : 1. The tertian, which sporu- 
late at the end of four hours, begin as small amoeboid intracorpuscular 
bodies, gradually enlarge, produce fine brownish pigment-granules, and 
finally completely fill the corpuscle. In sporulation the segments 
number fifteen to twenty. 




Malarial plasmodia. (Reproduced from colored plate.) To the right two normal red blood-cells 
with central depression. In addition, several others with bluish contained bodies and pigment- 
sprinkled cells, which show the endogenous development of the plasmodia. Besides, two of 
Laveran's bodies, one exhibiting a delicate little basket appearance. Near the centre a poly- 
nuclear white cell with bluish nuclei and red granulation. (H. Rieder.) 



2. The quartan, which sporulate at intervals of seventy-two hours, 
are smaller ; amoeboid movement is not so marked ; when full grown 



THE DATA OBTAINED BY OBSERVATION. 283 

Fig. 61. 



R? 



V 



SL 



? 3 



8m 



w 



«« -.*&>« 



yr y 





,C"% 






j, . #* 






v. '") 



J< 



mm 



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The first twelve figures show the malarial Plasmodium. It is a pale amoeboid body inside the 
red corpuscle. It increases in size at the expense of the corpuscles. In the last four of the twelve 
it is enlarged and contains pigment-granules derived from the haemoglobin. The figures of the 
fourth row show progressive stages in the process of cleavage of the Plasmodium and shifting of 
the pigment-granules. In the fifth row the process of cleavage is seen to be completed, and final 
isolation of the spores has taken place. The dark granules are pigment-granules. The last row 
shows oval parasites— La veran's corpuscles observed in h typical cases of malaria. (From Golgi, 
"Studien iiber Malaria," Forlschritte der Medicin, Bd. iv. Tafel., m.) 



284 GENERAL DIAGNOSIS. 

the parasites are smaller, and the corpuscles tend to shrink about them 
and to become a deeper greenish color. They sporulate with five to 
ten segments in a very beautiful characteristic roseate appearance. 

3. The sestivo-autumnal are smaller, and contain less pigment. The 
period of sporulation is still in dispute. They usually form ovoid- 
crescentic or round bodies with coarse pigment-granules in the centre. 

Golgi maintains that in tertian malarial fever the period between 
invasion of the corpuscles and the sporulation is two days ; in quartan, 
three days, the difference in cycle being due to a difference in the 
parasites. 

The onset of the fever corresponds in time to the division of the 
parasites. 

The crescentic form described by Laveran is said to be more common 
in the irregular forms of malarial fever. Canalis says that it only 
makes its appearance several days after the first access of fever. It is 
somewhat longer than a red blood-cell, and the pigment tends to collect 
in a focus about the middle of the parasite. Subsequently it becomes 
oval and divides into eight or more daughter-cells. 

Another form with flagella is occasionally found. Councilman says 
it is most common in blood drawn directly from the spleen. 

The plasmodium of malaria may be stained as follows : Cover-glass 
preparations of the blood spread very thinly are dried in the air and 
fixed by immersion for twenty minutes or half an hour in a mixture 
of equal parts of alcohol and ether. They are then stained for twenty 
to thirty minutes in concentrated aqueous solution methylene-blue, 60 
parts ; \ per cent, solution eosin in 75 per cent, alcohol, 20 parts ; 
distilled Avater, 40 parts ; 20 per cent, solution potassium hydroxide, 
12 drops. The cover-glasses are then washed in water, dried, and are 
then ready for mounting. The red blood-cells are stained rose, the 
nuclei of leucocytes a deep dark-blue, and any plasmodia a delicate 
sky-blue. 

Aronson and Phillips' staining method is as follows : Make concen- 
trated aqueous solutions of orange G., acid rubin, and crystallized 
methyl-green, leave them to settle, then mix in these proportions : 
Orange G., 55 ; acid rubin, 50 ; distilled water, 100 ; and alcohol, 50. 
To this add methyl-green, 65 ; distilled water, 50 ; and alcohol, 12. 
Leave the mixture standing for a week. A well-diluted solution 
should be used for staining purposes ; one drop of the mixture should 
be added to 25 cubic centimetres of water ; the stain should be left on 
for twenty-four hours and the fixing of the preparations carried out at 
a temperature of 120° C. In the result the red corpuscles are stained 
orange, nuclei greenish blue, neutrophile corpuscles violet, and eosin- 
ophile red. 

The examination of the blood discloses the presence of a high degree 
of anaemia. The haemoglobin is usually diminished in greater propor- 
tion than the corpuscles. There is a marked reduction in the leuco- 
cytes. Thus leucopenia is most marked after a paroxysm. There is 
a relative diminution of the polynuclear forms and a relative increase 
in the mononuclear forms. In severe post-malarial anaemias, as Thayer 
points out, the blood is characteristic of pernicious anaemia. 



THE DATA OBTAINED BY OBSERVATION. 



285 



Irregular Form. Irregular forms of intermittent fever are more 
common in Philadelphia than the typical form just described. 

In the mild form the patient complains of great lassitude, irritability 
of temper, and drowsiness during the day, but at night tosses upon his 
bed and gets up in the morning more tired than when he went to bed. 
The back and limbs ache, and the latter feel as though they would 
give way under him. There is severe throbbing headache, with some 
dizziness and faintness. The bowels are constipated ; the tongue 
heavily coated with yellow fur. The temperature is moderately eleva- 
ted and the patient has great thirst. Nausea and vomiting are absent, 
though there is little desire for food. There may be a burning feeling 
referred to the splenic region. The patient is worse on alternate days, 
and the attacks may be preceded by slight creeping chills. On inquiry 
the patient will be found to live in a low-lying district near one of the 
rivers, or in a damp house over an unclean, moist cellar, or adjoining 
a place where fresh soil has been upturned. 

In the form known as " dumb ague" there is a periodically great 
depression, with aching in the head and limbs, a sensation of coldness 
rather than chilliness, but no marked fever and sweating. Nausea 
and vomiting may, however, be present. Da Costa says he has seen 
it manifest itself by excruciating pain over the kidney, and almost 
entire suppression of urine. There may also be severe paroxysms of 
gastralgia. It is more common in old residents of malarious districts. 

In masked malarial fever the poison manifests itself in an attack of 
neuralgia, especially of the supraorbital nerve and gastric nerves. 
Malaria may also be latent until some impairment of the resisting 
power brings it to light. Hence it appears as a complication of pneu- 
monia and dysentery and typhoid fever (Fig. 62), especially in the 



Fig. 62. 

■4THvyEEH 





m 




K 



limi 



\/M\r 



Cold tub-baths 



Abundant malarial 
organisms. 

Malarial fever associated with enteric fever. (Thompson.) 



southern and southwestern portions of the United States. Moreover, 
women who have previously had intermittent fever may suffer a recur- 
rence after confinement. 

Diagnosis. The essential points in the diagnosis of intermittent 
fever are the periodical recurrence of paroxysms of chill, fever, and 
sweating, or of attacks of dumb ague, or of paroxysms of neuralgia, 
without organic lesion, associated with the presence in the blood of 
pigment and plasmodia, and with enlargement of the spleen and possi- 
bly of the liver. The so-called therapeutic diagnosis may be made — 



286 



GENERAL DIAGNOSIS. 



an intermittent fever which does not yield to proper doses of quinine 
in three days is not malarial. A typical malarial intermittent fever is 
not likely to be mistaken for anything else. (See Fever, pages 205, 
206.) It needs, however, to be distinguished from septiccemic fever, 
due to absorption into the blood of pus and the toxins produced by 
bacteriological growth. Such fever occurs in tuberculosis, especially 
in the stage when cavities form and pus collects ; in the puerperal 
state, in empyema, subphrenic abscess, abscess of the liver, or, indeed, 
in any form of suppuration. Here also, then, are recurring chills, 
with fever and sweating, but the attacks are not regularly periodical 
and intermittent ; sometimes the fever is intermittent and sometimes 
remittent, the chills recur at irregular intervals, and are not so violent 
as in the malarial attack. The essential difference, however, lies in 
the fact that a local cause can be found to explain them, tuberculosis 
either of the lung or of some other viscus, or a collection of pus in an 
organ or cavity, or a foetid discharge from the womb, with local ten- 
derness or peritonitis ; moreover, the patient loses flesh more or less 
rapidly, his blood is free from malarial germs and pigment, and quinine 
does not control the fever. (Plate VI., Fig. 2.) 

From the intermittent fever of hepatic origin (described elsewhere 
by the author) the diagnosis is more difficult, in that physical signs of 
any local trouble may be wanting. But the fever is not regularly 
intermittent, is not controlled by the quinine, but may be by measures 
directed to the origin of the trouble, and jaundice may be present. 



Fig. 63 




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81 » •+ H o r-30O 2 " 



A form of intermittent fever from syphilis. J. D., aged twenty-six years. Secondary period. 
Mercury and iodide of potassium relieved it. Observe that the pulse-frequency is not increased. 



Urethral fever , occurring as the result of operations upon the urethra, 
or simply from the passage of a catheter or bougie, may be mistaken 
for malarial fever ; but the paroxysm is usually single, and the history 



THE DATA OBTAINED BY OBSERVATION. 287 

of the operation and the absence of plasmodia from the blood clear up 
the diagnosis. 

Syphilitic fever is distinguished by a tendency for the chill, fever, 
and sweating to be nocturnal in recurrence, and by evidence of a syph- 
ilitic infection coupled with absence of malarial germs from the blood. 

Remittent Malarial Fever. ^Estiva-autumnal Types. A type 
of malarial fever characterized by a remission instead of an intermis- 
sion in the febrile paroxysms. It is due either to a greater intensity of 
the malarial poison or to a different species of organism. It is much 
more rare in temperate climates than either quotidian or tertian inter- 
mittent, and is attended with more gastric disturbance and a much 
larger mortality (twelve times greater, according to the statistics of 
the civil war). 

The onset is more abrupt than in intermittent fever. Prodromata 
are not so common, but when they occur they are of the same charac- 
ter. The chill is not usually so violent, nor the cold stage so long as 
in intermittent fever ; on the other hand, nausea and vomiting are 
common, and in some cases there are bilious vomiting and diarrhoea, 
tenderness over the stomach and spleen, and sometimes jaundice. The 
temperature rises rapidly from 103° to 106°, and remains high for a 
longer time than in intermittent fever, the hot stage lasting in severe 
cases from six to eighteen or twenty hours. 

During this time the patient suffers from headache, pains in the back 
and limbs, great thirst, and gastric irritability. A remission now suc- 
ceeds. The temperature falls two or three degrees, but not to normal ; 
free sweating occurs, the nausea and vomiting cease, and the patient 
becomes much more comfortable. He may fall asleep from exhaus- 
tion, but if awake is conscious of weakness, aching in the limbs, and 
perhaps nausea. In the course of some hours the temperature again 
rises, often to a higher point than before, but frequently without ante- 
cedent chill. The same subjective symptoms are repeated, and another 
remission follows. Daily paroxysms usually occur, those on alternate 
days being severe. The temperature often reaches its highest point at 
the third paroxysm. The disease generally runs its course in from 
nine to twelve days, but it may last much longer. The type of fever 
may change to intermittent, which is a favorable sign, or become con- 
tinued and again remittent, or remain remittent throughout ; finally, the 
fever may subside gradually, or, less commonly, by crisis. The urine 
is febrile but not albuminous. (See Examination of Blood, page 282.) 

Pernicious Malarial Fever. This, as the name implies, is a form 
of malarial fever with destructive tendency. It is also called malig- 
nant and congestive fever. It may be intermittent or remittent. Nearly 
24 per cent, of the cases occurring in the U. S. Army from May 1, 1860, 
to June 20, 1866, proved fatal. 

Bemiss l divides it into three classes : the algid, or congestive, form ; 
(2) the comatose form ; (3) the hemorrhagic form. To this another 
class, (4) the gastro-enteric form, may be added. It is important to 
remark that the first paroxysm does not usually, in any of these forms, 

1 Pepper's System of Medicine, 1885, vol. i. 666. 



288 GENERAL DIAGNOSIS. 

indicate that the type of the disease is pernicious. The first seizure 
may, however, prove fatal. 

1. The algid form, according to Bemiss, occurs more frequently 
than any other, its perniciousness being due to an aggravation of the 
cold stage of an intermittent attack. The patient is extremely weak, 
with cold extremities, pinched features, blue lips, and faint voice. 
Respiration is shallow, the pulse rather slow, feeble, and irregular ; he 
is further exhausted by vomiting and liquid, offensive diarrhoea, the 
passages sometimes being involuntary. There may be copious per- 
spiration, but the internal temperature is very high. The mind may 
be clear, or there may be deep stupor. Unless speedy relief can be 
afforded the attack ends fatally. 

2. In the comatose form the patient is completely unconscious, the 
skin hot " and of a muddy, semi-jaundiced hue " (Bemiss). Both 
pulse and temperature are increased. In other cases coma is preceded 
by wild delirium, resembling acute meningitis. 

The comatose form is most apt to occur in those who continue to 
reside in a malarious region without proper safeguards against its 
poisonous influences. 

3. In the hemorrhagic form there has been, as a rule, previous alter- 
ation of the blood, the bloodvessels, and other tissues, by long-con- 
tinued malarial poisoning or cachexia. Then, when intense congestion 
of these parts occurs as the result of the surface-chill, hemorrhage 
follows. In some districts, however, and at certain seasons, there has 
been a special predilection of the poison for the kidney, with resulting 
hsematuria. The prominent symptoms are a prolonged chill with high 
temperature ; nausea and vomiting, sometimes with the expulsion of a 
greenish-black fluid ; oedema of the lower extremities ; general anasarca 
and occasionally oedema of the lungs, and hyclrothorax ; bloody and 
albuminous urine, with tube-casts ; and intense jaundice. Pain in the 
right hypochondrium or over the kidneys is common. 

Bemiss asserts that uncomplicated malarial fever has not a hemor- 
rhagic tendency. 

4. The g astro-enteric form has for its prominent symptoms nausea, 
vomiting, diarrhoea, intense thirst, extreme restlessness, a frequent, 
feeble pulse, and urgent dyspnoea. " The breathing is deep-drawn ; 
to each expiration succeed two respirations " (Da Costa). The patient 
is cold and partly collapsed. Reaction may or may not occur. 

The patient may have several paroxysms of pernicious malarial 
fever and succumb in any one of them. Convalescence is slow. The 
most frequent sequelae of malarial fevers are anaemia, neuritis, and 
paralyses, and malarial cachexia. 

Typhoid fever is distinguished from pernicious malarial fever by its 
gradual onset, the absence of chills and vomiting, as a rule, and, on the 
other hand, the presence of epistaxis, delirium, and ataxic symptoms, 
tympanites and diarrhoea, with pale-yellow watery stools, and rose- 
colored spots. The temperature in typhoid is more continuously high, 
the daily oscillations being of shorter range. A history of exposure to 
malarial infection and of previous attacks can often be obtained. The 
urine of typhoid exhibits the diazo reaction ; malarial fever does not. 






THE DATA OBTAINED BY OBSERVATION. 289 

Malarial cachexia occurs especially in those who have lived for a 
loner time in malarious regions. Thev may or may not have had 
typical malarial attacks. The patient suffers with dyspepsia and con- 
stipation, with occasional bilious attacks ; the face is of a pale lemon- 
yellow color, and may be slightly jaundiced ; there is marked anaemia, 
with pigment and crescentic and flagellate forms of plasmodia in the 
blood, together with great enlargement of the spleen (ague-cake) and 
some enlargement of the liver. The patient is weak and languid, and 
sometimes has considerable mental depression. 

Serum Diagnosis. 

The infections just described are recognized by an examination of 
fresh blood or cover-slip preparations. The next group of infections 
may be recognized by serum diagnosis. Too much stress must not be 
placed upon this method of diagnosis, yet its value is so great that 
one is fully justified in giving it a high place in the precise method of 
diagnosis of infections. 

Typhoid Fever. 

The first of the infections to which such diagnosis has been applied 
in extenso is typhoid infection or typhoid septicaemia. This infection 
is caused by the bacillus typhosus. The most common expression of 
it is seen in a symptom complex which attends a septic process and 
local intestinal ulceration, which symptom complex we know as 
typhoid fever. This infection, it is stated by some, is unattended in 
rare instances by fever. More frequently a febrile course, following 
a definite continued type of a duration of from twenty-one to twenty- 

i eight days, prevails. In mild or abortive forms fever rarely reaches 
103°, and declines from the seventh to the fourteenth day. In the 
grave forms the fever is often very high and attended by cerebro-spinal, 
renal, pulmonic, or severe gastro-intestinal symptoms. 
The most important infection prevailing in the temperate zone is the 
one we are now about to consider. It is an acute, specific, infectious, 
and mildly contagious fever, characterized by a gradual onset, a con- 
tinued fever, an eruption of rose-colored spots, marked nervous and 
abdominal symptoms, and an average duration of three or four weeks. 
It occurs sporadically and epidemically, and in large cities is apt to 
be epidemic. Its special habitat is in temperate climates, but it may 
occur anywhere. It is relatively rare in the southern and southwestern 
portions of the United States. It is more frequent in the latter part 
of the summer and in the autumn and winter, and following hot and 
dry summers. Young adults are especially prone to it, but cases have 
occurred at all ages. Change of residence from the country to the city 
predisposes to it. Those living in cities often acquire immunity, but 
they may lose it upon moving elsewhere. The state of previous health 
does not seem to have any influence. 

The period of incubation in typhoid fever varies from four or five 
days to three weeks ; more commonly it is from one to two weeks. 
During this time the patient usually is languid, becomes tired easily 

19 



290 GENERAL DIAGNOSIS. 

upon exertion, has severe headache, sleeps poorly, and has bad dreams. 
There is often, even thus early, a dull and listless expression of the face. 
Toward the close of this period, and in severe cases, there may be 
colicky pain in the abdomen, a tendency to looseness of the bowels, 
cough, epistaxis, mental sluggishness, and chilliness. Dr. Pepper says 
he has been led repeatedly to anticipate the approach of typhoid fever 
by the unusual dulness of hearing and by the persistent occipital head- 
ache coming on after a few days of general malaise. 

While the disease may begin abruptly, a gradual onset is so much 
the rule that it becomes important in the diagnosis from other disease- 
conditions. 

Invasion is not sharply marked. There may be chilliness, but a 
decided chill is unusual except when pneumonia is part of the initial 
process. Muscular weakness, headache, and mental sluggishness are 
more pronounced, and the physician is consulted because these symp- 
toms persist, or because fever is discovered. The beginning of fever 
is the most constant indication of the onset of the disease, and two 
very important early symptoms are cough from bronchitis and en- 
largement of the spleen. 

The most prominent and constant subjective symptom during the 
first week is headache. Other very common symptoms are tenderness, 
rarely pain, in the iliac region, more or less prostration, and impaired 
appetite or loss of appetite. 

The objective symptoms are therefore the most important. The face 
is pale rather than flushed, and has a dull, listless, apathetic expres- 
sion. The tongue is heavily coated with a white fur which later 
becomes yellow. The abdomen is somewhat distended and tympanitic 
on percussion. There is usually tenderness in the right iliac region, 
and gurgling upon palpation is pretty constant. Constipation may 
be present at first, and sometimes persists throughout the disease. A 
tendency to diarrhoea is, however, characteristic of the disease. Even 
if constipation exists at first, a laxative is apt to produce an excessive 
effect. The number of stools varies from two or three to a dozen or 
more in twenty-four hours. They are light yellow in color (resem- 
bling pea-soup), thin, watery, and offensive. The movements are not 
usually attended with pain, and in severe cases may occur involuntarily. 

Enlargement of the spleen is a very constant symptom. It may be 
detected at the onset, increases up to the height of the fever, subsides 
during convalescence, but recurs during a relapse. It covers a percus- 
sion-area in the left hypochondrium of four to eight finger-breadths. 

The temjieratur e-curve, when not modified by treatment, shows a 
gradual ascent during the first four or five days of the disease, with 
morning remissions. The temperature rises a degree or two in the 
evening and falls half a degree or a degree in the morning. This 
" step-ladder " ascent is very characteristic. By the end of a week a 
temperature of 103°, 104°, or 105° has been reached, and it remains 
continuously high, with slight morning remissions, during the second 
and less frequently during the third week. In the third or fourth 
week the morning fall of temperature gradually becomes greater, and 
by the end of the week sinks below the normal in the morning. 



THE DATA OBTAINED BY OBSERVATION. 



291 



The temperature in mild cases may never rise above 103° at any 
time, and most of the time varies between 100° and 102°. Or it may 



Fig. 64. 



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104 

o 

103 
102 

101° 

o 
100 

99 

DAY OF DIS. 
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September Oct. 

Temperature ranges ; first week of typhoid fever. (Dock.) 

be 104° from the start ; more frequently during the second and third 
weeks there are marked oscillations of the temperature — a sudden fall 
from 104° to 101°, or a rise from 103° to 105° or 106°. Hyperpy- 
rexia is a temperature above 105°. 

Fig. 65. 



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Mild typhoid fever. Gradual ascent. 



The pwfee is full, and in favorable cases slower than the pyrexia 
would lead one to expect. It is more frequently under 110 than over 
120. In the second week it is markedly dicrotic. 



292 



GENERAL DIAGNOSIS. 




THE DATA OBTAINED BY OBSERVATION. 



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294 GENERAL DIAGNOSIS. 

The heart sounds are unchanged apart from complications, but in the 
second and third weeks the first sounds often are feeble, indicating 
heart weakness. A pulse of 120 or more is a graver sign in typhoid 
fever than in other diseases. Therefore, when it becomes very frequent 
and feeble, the extremities cool and the lips bluish, the outlook is 
gloomy. 

The urine is at first scanty and high-colored. A slight degree of 
febrile albuminuria is not uncommon, and in rare cases the whole force 
of the poison seems to be spent upon the kidneys, the urine containing, 
besides the usual blood and casts, biliary coloring-matter. In condi- 
tions bordering on coma the patient may have retention of urine, or, 
on the other hand, he may pass it involuntarily. To obtain the diazo 
reaction of Ehrlich two solutions are necessary. The first (a) consists 
of 2 grams of sulphanilic acid, 50 c.c. hydrochloric acid, and distilled 
water 1000 c.c. The second (b) consists of a J per cent, solution of 
sodium nitrite. These solutions are kept in separate bottles. Fifty 
parts of solution a and one part of solution b are poured into a test- 
tube and an equal volume of urine added. The test-solutions and 
urine are now thoroughly shaken and then carefully overlaid with 1 
c.c. of ammonia. At the junction of the two a pink or ruby ring 
develops. Upon agitation the foam on the top of the mixture is also 
colored red. Normal urine gives a light brown ring. This reaction 
is helpful in diagnosis, but may occur in acute phthisis, tubercular 
meningitis, and other diseases. According to Pepper, it is rarely 
absent in measles. The reaction is fairly constant in typhoid fever 
after the first week. 

The respiration in uncomplicated cases increases in frequency with 
the rise in temperature. It usually ranges between 24 and 36. The 
slight bronchitis present in the beginning in most cases causes no 
trouble ; sometimes it lasts throughout and contributes to the tendency 
to hypostatic congestion, which is always present. The physical signs 
are those described elsewhere in these conditions. 

The nervous symptoms are often very prominent. In mild cases 
they consist of hebetude and nocturnal delirium, or they may be absent 
altogether. Usually, however, by the beginning of the second week, 
there is some mental confusion, with nocturnal delirium. In more 
severe cases, and later in the disease, the delirium is of a low, mutter- 
ing character, with hallucinations of sight and sound more or less 
continuous. The patient can be roused by a question, and makes an 
intelligent answer, but speedily lapses into semi-consciousness. Pick- 
ing at the bedclothes or efforts to catch imaginary objects are very 
common. Sometimes the delirium is wild and noisy, and the constant 
presence of some one is needed to keep the patient from getting out of 
bed. Patients have jumped out of windows, or run long distances 
before being captured. Rarely the delirium has been so active as to 
simulate acute mania. Stupor may alternate with delirium. Rarely 
the patient lies with wide-open eyes, apparently staring fixedly at 
some object, but really unconscious (coma-vigil). 

In ataxic cases the patient has marked twitching of the tendons and 
jactitation. He is wakeful and restless, wearing himself out. The 



THE DATA OBTAINED BY OBSERVATION. 



295 



hands and lips tremble, and lie keeps muttering to himself all the 
time. 

Convulsions are rare, but may occur in children. Sometimes there 
are considerable hyperesthesia and tenderness along the spine. 



Fig. 68. 



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Fig. 69. 





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Typhoid fever in a child aged 12 years. Chart from twelfth to twenty-third day. 
Kepeated crises. (Frequent mode of termination in children.) 

The extent of the nervous symptoms depends upon the habit of the 
patient as well as upon the height of the temperature and gravity of 



296 



GENERAL DIAGNOSIS. 



the disease. In children and neurotic individuals they may be pro- 
nounced, with only moderate fever. 

On the seventh or eight day the eruption appears. It consists of 
small, very slightly elevated, rose-colored papules, which disappear 
upon pressure and come out in successive crops, each papule lasting 
three or four days. The spots are most common over the abdomen 
and back, but are occasionally found elsewhere. They are usually few 
in number, a half-dozen or dozen, but sometimes the eruption is very 
copious, especially in severe cases. Sometimes it is wholly absent. 

During the latter part of the second week, and through the third 
week, the symptoms are apt to be intensified. The temperature keeps 
up or even reaches a higher point. Delirium is more decided and con- 
stant. The heart grows weak and the pulse increases in frequency. 
Some degree of hypostatic congestion of the lungs is usual. Diarrhoea 
may be troublesome ; intestinal hemorrhages, announced by sudden 
fall of temperature and symptoms of collapse, may occur. Tympanites 
may become so great as to interfere with respiration and circulation. 
This is the period when ulceration of Peyer's patches in the intestine is 
deepest, and when perforation is imminent. There is rarely any desire 
for food, though it is taken and assimilated. Nausea and vomiting are 
rare. The tongue is dry, brown, sometimes glazed and fissured, and 
sordes often collect on the teeth. 

Fig. 70. 



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Course of temperature in a relapse beginning on the twenty-sixth day. First attack mild. 



In cases ending in recovery the temperature begins to fall in the 
mornings ; delirium grows less ; sleep is more refreshing. Diarrhoea 
ceases, and constipation may even require treatment. The pulse does 
not usually improve as rapidly as the other symptoms. There is some- 
times very marked anaemia without leukocytosis (Osier). When the 



THE DATA OBTAINED BY OBSERVATION. 



297 



temperature sinks to normal or subnormal, convalescence has set in. 
This is very rapid as far as digestive symptoms are concerned, but 
strength returns very slowly. It may be interrupted by a relapse, in 
which the original symptoms are reproduced, with high temperature, 
but the duration is shorter. 

Varieties. It is now well known, as Osier forcibly states, " that 
typhoid fever is no more primarily intestinal than is smallpox prima- 
rily a cutaneous disease." Studies in bacteriology, promoted especially 
by Chiari, Flexner, Kraus, Mcholls, and others, enables us to divide 
the infection into three varieties : 1. Typhoid fever with intestinal 
lesions, as described above. 2. Typhoid fever with general infection 
or typhoid septicaemia. The symptoms are entirely those of an infec- 
tion, and the diagnosis must rest upon the serum reaction and culture 
methods. 3. Typhoid fever with more intense infection of other organs 
than the intestines. The lungs, the spleen, the kidneys, and the cere- 
brospinal meninges are the structures invaded, so that we may have a 
pneumo-, nephro-, spleno-, or cerebro-spinal typhoid. 



Fig. 71. 





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Varieties are also based upon the severity of the disease, hence we 
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The abortive form is so named because of the abbreviated course of 



298 GENERAL DIAGNOSIS. 

the disease. The symptoms are sufficiently well marked to make the 
diagnosis clear, but the type is mild, and in a week or two convales- 
cence is established. In rare instances an afebrile form with intestinal 
symptoms and eruption is seen. 

In the ambulatory form, commonly called " walking typhoid/' the 
patient, from ignorance of the gravity of his ailment or from apparent 
necessity, keeps at his work until weakness and incessant headache lead 
him to consult a physician in his office or at a dispensary. He may 
then be well into the second week of the disease. The majority of 
such cases prove fatal. 

Grave forms are due to especial severity of some symptoms or group 
of symptoms, such as hyperpyrexia ; profound stupor, coma, or intense 
ataxia ; inability to take or retain sufficient nourishment ; profuse diar- 
rhoea and intestinal hemorrhage ; great adynamia with weak heart and 
a tendency to cyanosis. In other cases the gravity results from the 
existence of complications. 

In the malignant form there has been a large dose of the poison or 
a very weak organism, or both, the result being an acute toxsemia; this 
is not so common as in scarlatina and typhus fever. 

In the pulmonary form the onset may be so obscured by severe 
bronchitis or lobar pneumonia that the primary disease is not suspected 
at first. Severe bronchitis seems to be more common in children. 
Chill and initial high temperature are common in these cases. 

Typhoid Fever without Intestinal Lesions. This rare form may 
present the clinical symptoms of typical typhoid, or may be of spleno- 
typhoid type, or of nervous type with extreme intoxication. The first 
type is rare. The second type, described by Eiselt, is characterized by 
an excessively large spleen, with local inflammation and remitting 
fever. In the third class the symptoms of the typhoid state with sub- 
cutaneous and visceral hemorrhage occur. Jaundice is more or less 
common. 

Complications and Sequelae. Typhoid fever may be accompanied 
by a number of complications, the most frequent and important being 
severe bronchitis, hypostatic congestion with oedema, and true lobar 
pneumonia ; bed-sores ; parotitis ; phlebitis, especially of the femoral 
vein ; peritonitis from perforation of the bowel ; meningitis, acute 
mania, or mental decay ; jaundice ; myocarditis ; periostitis and oste- 
itis. Sequela? are not frequent. Sometimes, however, the foundation 
is laid for permanent ill health. There may be impairment of the 
senses, mental weakness, and even insanity. Paralyses, neuritis, hyper- 
esthesia, chorea, and epilepsy are occasional sequels. 

Examination of the Blood. The infection is due to Eberth's 
bacillus, the bacillus typhosus. The bacillus is found in colonies in 
the spleen, liver, mesenteric glands, kidneys, and intestines. It is also 
found in the feces and rarely in the urine. It may be seen in the 
blood. It may be recognized by staining methods, although rarely. 
It has been isolated from the blood successfully, by culture methods, by 
Gwyn in a small number of cases. 

Morphology. A bacillus 1 to 3/z long by 0.5 to 0.8//. broad, with 
rounded ends. It is motile, facultative anaerobic, does not liquefy 



THE DATA OBTAINED BY OBSERVATION. 



299 



gelatin. It has flagella 3 to 5 times as long as the bacilli. It stains 
with the anilines, best with Loffler's bine. The flagella are stained 
by Loffler's special method. (See Plate III., Fig. 6, b.) 



Fig. 72. 





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Renal typhoid. 



Nephritis on the twenty-fifth day. Course of temperature during 
three days preceding death. 



Serum Diagnosis. This method of diagnosis has been more success- 
fully employed in typhoid fever than in any other infection. The 
methods have been previously described. The agglutinative reaction 
takes place as early as the eighth day, rarely as early as the third day, 
but sometimes not until the fifteenth or twentieth day, and even may 
not occur until convalescence is established. By this means typhoid 
fever can be distinguished from the infection due to the bacillus of 
Gartner (bacillus enteritidis). (See Lancet, January 15, 1898.) 

The paracolon bacillus infection, as shown by Gwyn (Bulletin of the 
Johns Hopkins Hospital, 1898, vol. ix. No. 84), who studied a case 
which resembled typhoid clinically, does not give this reaction. Influ- 
enza and Malta fever and forms of tuberculosis can also be distin- 
guished from typhoid fever by this method. 

Leucocytosis. A determination of the number of leucocytes is of 
value in the diagnosis of typhoid fever. It is one of the infections in 
which leucocytosis does not occur. In a differential count some varia- 
tion from the normal is seen. The large mononuclear and transitional 
forms are decreased ; the poly nuclear neutrophils are decreased. The 
absence of leucocytosis aids in distinguishing typhoid fever from vari- 
ous septic fevers and acute inflammations. On the other hand, in a 



300 GENERAL DIAGNOSIS. 

ease of typhoid fever if leucocytosis occurs an inflammatory complica- 
tion or mixed infection is possible. Perforation and peritonitis are 
attended by leucocytosis. 

In addition to the absence of leucocytosis we find, after the second 
or third week, gradual reduction of the red cells, and by the time con- 
valescence is established a marked anaemia develops. Both the red 
cells and the haemoglobin are reduced. 

Culture Methods. The bacillus can be isolated from the blood, the 
stools, and the urine. 

Biological Properties. The bacillus grows readily in acid 
media as well as in the neutral or alkaline media, best at a tempera- 
ture of 38° C. Death-point, 60° C. 

The colonies develop in twenty-four to forty-eight hours. On gela- 
tin plates they are small and white, nearly spherical ; irregular, granu- 
lar, and yellowish-brown. 

In stab-cultures there is a whitish semi-transparent layer on the sur- 
face, with sharply defined irregular edges, and along the puncture a 
grayish-white growth. (See Plate VII., Fig. 5.) It develops abund- 
antly in milk. On potato it forms an " invisible growth/' manifested 
only by increase in moisture, which is quite characteristic. 

Bacteriological Diagnosis. It would be most desirable if a 
means of diagnosis, that would have no element of uncertainty about 
it, could be found. Bacteriologists have sought for such means, and 
at present seem to have found two methods, one of which at least has 
been brought to such a degree of perfection as to be of value to the 
clinician. They are Eisner's culture and Pfeiffer's bactericidal serum 
methods. Eisner's method l consists in the preparation of a culture- 
medium upon which no species of micro-organism can grow except the 
typhoid bacillus and the bacillus coli communis. For a description 
of this complicated method the reader is referred to the recent works 
on bacteriology. 

Recently bacteriologists have been successful in isolating the typhoid 
bacillus from the stools and the urine. Unfortunately, the methods 
are too complicated for clinical work. P. H. His, Jr., recovered the 
bacillus typhosus and distinguished it from members of the colon group 
by a combined plate and tube method. 2 

For differentiation of the typhoid from the colon bacillus the method 
of Proskauer and Capaldi may be used. They employ two solutions. 
In solution No. 1 the typhoid bacillus does not grow at all. The colon 
bacillus grows rapidly, produces a marked acid reaction, and the blue 
color gives way to red. Solution No. 2 both bacilli grow, but the 
typhoid bacillus is the only one which gives an acid reaction. Note, 
the solutions are neutral in reaction and colored Avith litmus. 

Another method is that of Thoinot. He prepares a medium of 
bouillon, to which he adds y^ per cent, of arsenious acid. On it the 
typhoid bacilli do not grow, while the colon bacilli multiply rapidly. 

1 Zeit. Ilygien. und Infection ki\, B. xxi. H. 1. 

2 P. II. His, Jr., "On a Method of Isolating and Identifying Bacillus Typhosus," 
etc. Journal of Experimental Medicine, vol. ii. No. 6, p. 677. 



Fig. 1. 






PLATE VII. 

Fig. 2. 



Fig. 3. 




Streptococcus— Erysipelas. Streptoccocus Septicus. Staphylococcus. 
Fig. 4. Fig. S. Fig. 6. 

III! iii! 






DlPHTHKRIA-KACILLI. 



Typhoid-bacilli. Tuberculosis-bacilli. 



THE DATA OBTAINED BY OBSERVATION. 301 

Mark Richardson isolated bacilli in the urine of about 25 per cent, 
of the cases of typhoid examined. They were present in large numbers 
and in pure culture. They appeared late in the disease, and persisted 
into convalescence. The bacilli were always associated with albumin 
and casts. After disinfection of the meatus the urine is passed in two 
portions into sterilized test-tubes. The second portion is used. It is 
immediately plated upon plain agar. At the end of twenty-four hours 
the characteristic colonies appear. Richardson relies upon the active 
motility of the bacilli, which are set free in a typhoid colony by scar- 
ring with a platinum needle to distinguish them from the colon bacilli. 
He also used the dry serum reaction test. 1 

Pfeiffer's method, while of interest and full of suggestions as to its 
future usefulness, cannot be applied with sufficient ease to render it 
practical for clinical work. 

Inoculation. Thus far the results of inoculation have not proved 
satisfactory, and are certainly not of diagnostic value. 

Diagnosis. A typical case of typhoid fever ought not to be mis- 
taken for any other affection, but atypical cases are numerous. The 
most common sources of error are a hurried diagnosis and a willing- 
ness to accept a demonstrable local affection as sufficient to account for 
the condition. In this way the significance of bronchitis, pneumonia, 
and diarrhoea is overlooked. In the symptomatic form there will 
almost always be found a history of gradual onset and a degree of 
fever and prostration greater than should attend the purely local affec- 
tion. Moreover, in bronchitis and pneumonia, which are a part of 
typhoid fever, there may be found tenderness with gurgling in the 
right iliac region, enlargement of the spleen, and epistaxis, to aid in 
the diagnosis ; while in cases in which the diarrhoea leads to uncer- 
tainty, bronchitis, enlargement of the spleen, and epistaxis may coexist. 
Examination of the blood, extended over a period of several days, is 
necessary to exclude the cestivo-autumnal type of malarial fever, which 
often resembles typhoid fever. 

New Diagnostic Sign of Typhoid Fever. Dr. Simon Baruch 
writes as follows : " As soon as the patient shows a rectal temperature 
above 102.5° in the morning and 103° in the evening for three succes- 
sive days, especially if this be accompanied by headache, dulness, or 
apathy, he is placed in a full bath at 90°, which is reduced to 80°, 
with constant friction over the body. In three hours, the temperature 
still being above 102.5°, he receives another bath 5° cooler. This is 
repeated until the temperature of the bath is 75°. If one or more of 
these baths fail to reduce the rectal temperature 2° in half an hour, the 
diagnosis of typhoid fever is almost certain, and the bath-treatment is 
continued. The resistance of the rectal temperature to a bath of 75° 
for fifteen minutes, with friction, is an almost certain test of typhoid 
fever." 2 Dr. Baruch considers that the diagnosis of this disease should 
no longer be obscure, even in the first days of its course. 

1 Kichardson, M. W., "On the Presence of the Typhoid Bacillus in the Urine." 
Journal of Experimental Medicine, vol. iii. No. 3, p. 349. 

2 New York Medical Journal, September 2, 1893. 



302 GENERAL DIAGNOSIS. 

Appendicitis is more likely to be mistaken for typhoid fever than 
the converse. There is usually a history of constipation, though the 
occurrence of several inadequate movements a day may conceal the fact 
that there is a f aecal accumulation. In appendicitis the onset is more 
abrupt and the local symptoms more pronounced than in typhoid. 
Pain and tenderness are prominent in appendicitis, and while they may 
be general over the abdomen at first, they are found to be more acute 
in the iliac region and loin. Here, in place of gurgling, we find some 
increase of resistance on palpation, and a relatively dull note — a 
wooden sort of tympany — or there may be a demonstrable tumor. 
The patient lies with the right leg drawn up, has moderate fever, and 
vomiting. In fact, the attack is often introduced by chilliness and 
vomiting. Headache is not a prominent symptom, while bronchitis 
and enlargement of the spleen are absent. 

Acute right-sided salpingitis simulates typhoid fever. It is distin- 
guished by the history of a preceding vaginitis, endometritis, or abor- 
tion, by the absence of diarrhoea, of enlargement of the spleen, and of 
the characteristic eruption. A digital examination through the vagina 
discovers the womb pressed to one side and fixed, and a tender mass 
blocking up the pelvis. 

Simple continued fever is distinguished from typhoid fever of a mild 
type principally by the absence of bronchitis, of enlargement of the 
spleen, of epistaxis, and of the characteristic eruption of typhoid fever. 
In simple continued fever constipation is more common than looseness 
of the bowels, and gurgling is absent. 

Typhus fever is distinguished by its sudden onset, the besotted ex- 
pression of the face, with reddened eyelids and small pupils, the 
absence of abdominal symptoms, and the occurrence on the fourth day 
of maculae, which are subsequently converted into petechia?. It is of 
shorter duration, and terminates very abruptly by crisis. 

Relapsing fever differs from typhoid fever in its sudden onset with 
chill, pain in the epigastrium, but absence of abdominal symptoms and 
eruption ; in the absence of marked nervous symptoms, in spite of the 
high fever ; the short duration and termination by crisis, and the char- 
acteristic relapse at the end of a week. The conclusive test is finding 
spirilla in the blood. 

Acute tuberculosis of the lungs, at times, closely resembles typhoid 
fever. In both the onset is gradual, with cough and fever. In the 
former, however, the bronchial symptoms are more prominent, there 
are apt to be recurring chills and sweats, the temperature is remittent 
and irregular, emaciation is rapid, and constipation instead of diarrhoea 
is the rule. 

In peritoneal tuberculosis there is persistent diffused pain in the 
abdomen ; the belly is swollen. If effusion occurs, the physical signs 
disclose its presence. The temperature is irregular and may be below 
normal ; nervous symptoms comparable to those of typhoid are 
wanting. 

Meningitis before the stage of effusion exhibits exaggeration of the 
reflexes and marked hyperesthesia. There may also be muscular 
rigidity. The patient is restless, easily annoyed, and " fussy " about 



THE DATA OBTAINED BY OBSERVATION. 303 

things that would be unnoticed by a typhoid patient. Vomiting is 
often present, whereas it is rare in typhoid fever. The temperature 
does not maintain so high an average range as in typhoid fever, and is 
subject to greater oscillations. The pulse varies greatly, and may be 
irregular. 

In septic meningitis the headache and vomiting are more persistent, 
the bowels are confined, and the abdominal walls are retracted. There 
may be double optic neuritis. In tubercular meningitis the knee-jerk 
and other reflexes are variable, irregularly absent or present. In 
typhoid fever they are always present. In the former choroidal tuber- 
cles may be seen with the ophthalmoscope. In tuberculosis in all 
forms leucocytosis is present ; in typhoid it is absent. Typhoid fever 
must not be confounded with trichiniosis ; the peculiar muscular pain 
and oedema do not occur in the former. Urcemia may simulate typhoid 
fever when it becomes chronic ; but the age, the character of the urine, 
the cardio- vascular symptoms, are diagnostic, and, with the absence of 
the specific typhoid symptoms, render the diagnosis easy. 

Mountain Fevek is an infection which has been described as pecu- 
liar to the mountains of our Western States, characterized by a con- 
tinued fever with intestinal symptoms not unlike those of typhoid 
fever. Irregularity of the temperature-range and the occurrence usually 
of constipation rather than diarrhoea make it difficult to classify the 
infection from typhoid fever on the one hand and from forms of ma- 
laria on the other. Recent observations of Woodruff, who studied the 
serum reaction in a large series of cases, show conclusively that the 
infection is typhoid fever, confirming the prior observations of Hoff, 
Smart, and Raymond. 

Yellow Fever. 

The infection which we are about to consider is the latest of the 
epidemic and contagious disorders for which a definite causal micro- 
organism has been discovered. It is an acute, specific, contagious, 
miasmatic disease, endemic and epidemic on the tropical and subtropi- 
cal shores of the Atlantic Ocean, characterized by a sudden onset, a 
duration of a week or less, a characteristic facies, a fall in the pulse- 
rate preceding a fall in temperature, and by albuminuria, jaundice, and 
vomiting, with a tendency to hemorrhages. The specific micro-organ- 
ism is the bacillus icteroides describeol by Sanarelli. 

Yellow fever is endemic in Havana and other seaport cities of Cuba, 
and in Rio Janeiro, Brazil. From these centres it is liable to become 
epidemic, and to be carried in ships and by persons and clothing to 
other places. In this way epidemics have developed in the seaports 
of the United States, especially in the south around the Gulf of Mexico, 
but sometimes as far north as Philadelphia and New York. The 
disease becomes epidemic in the hot season and ceases upon the appear- 
ance of frost. The specific germ has not yet been isolated. 

In countries in which the disease is endemic it is the custom to 
regard the native children as immune. Dr. John Guiteras, however, 
is strongly of the opinion that the disease is kept alive between epi- 
demics by cases among these children. He has also shown that it 



304 GENERAL DIAGNOSIS. 

prevails among white children before it becomes epidemic among 
adults. 

The period of incubation varies from a few hours to two weeks. 
Guiteras states that the cases in which it extends beyond the seventh 
day are exceptional. 

The invasion is abrupt, and occurs usually in the night. It is marked 
by chilliness oftener than by a decided chill. The temperature rises 
rapidly to 102° to 103° or 104°, not often higher in favorable cases. 
The pulse is correspondingly increased in frequency at first, but very 
commonly begins to fall before the temperature, so that later the pulse 
is relatively slow. The face is peculiar and characteristic — it is flushed 
and somewhat swollen ; the eyelids are somewhat swollen, with red- 
dened edges ; the eyes are watery, glistening, and slightly but dis- 
tinctly tinged with yellow ; the pupil is small and brilliant. Guiteras 
says : l " The appearance of the face is often sufficiently characteristic 
on the first day of the disease to warrant a positive diagnosis/' " The 
early manifestation of jaundice is undoubtedly the most characteristic 
feature of the facies of yellow fever." He also says that these phe- 
nomena are often better observed at a slight distance than on close 
inspection. 

The tongue is large, moist, and coated with white fur. The stomach 
is irritable and the epigastrium tender. Nausea with repeated vomit- 
ing occurs. The fluid is at first of a light greenish-yellow, subse- 
quently becoming decidedly bilious. The bowels are constipated. 

The urine almost invariably contains albumin at some time during 
the first three days. Its presence may be very transient. It may be 
found in the evening and not at other times. The amount of albumin 
is sometimes very large, and abundant blood and tube-casts are found. 

The nephritis subsides rapidly, without leaving traces. The urine 
is acid in reaction and scanty in amount. It is sometimes suppressed. 

During this febrile period the patient complains of headache, pains 
in the back and limbs, and intense thirst. The mind, however, is 
usually perfectly clear. Contrary to expectation, Guiteras asserts that 
the nervous symptoms are, perhaps, more prominent in the adult than 
in the child. " The loquacity, the short-cut phrases and precipitate 
speech, the excitement, the show of indifference with unmistakable evi- 
dences of fear — all these, that are such prominent features of the dis- 
ease in the adult, are absent in the young." 2 

In from two to five days the temperature falls to or below normal, 
headache and pains in the limbs disappear, and the patient is cheerful 
and thinks himself convalescent. This is the fact in mild cases, but 
in more severe cases the period of remission or stage of calm is followed 
by a return of symptoms in a few hours or at most a day or two. The 
jaundice deepens, vomiting becomes more urgent and in adults is accom- 
panied by much retching. It is bilious, streaked with blood, or thick 
and wholly black (" black vomit ") ; the temperature may rise again 

1 " .Report of the Surgeon-General of the Marine-Hospital Service, 1888;" Keat- 
ing's Cyclopaedia of Diseases of Children, 1889, vol. i. 

2 Keating's Cyclopaedia, loc. cit. 



THE DATA OBTAINED BY OBSERVATION. 305 

as high as, or higher, than in the original paroxysm, or it may remain 
depressed. In any event the pulse is apt to be slow, often from 40 to 
60. The urine contains albumin, blood, and casts, and may be sup- 
pressed, adding uraemia to the other toxaemia. Convulsions at this 
stage are usually ursemic. Hemorrhages may occur from any mucous 
surface. The gums are tender, swollen, and bleed easily. There may 
be epistaxis, hemorrhage from the ear, bowel, uterus, or vagina. Preg- 
nant women miscarry. Ecchymoses also may form. Death may take 
place in coma or convulsions. If the patient lingers beyond the fifth 
or sixth day he sinks into a typical typhoid state, with diarrhoea and 
marked adynamia, from which he may or may not emerge. 

As in scarlet fever, the patient may be smitten down and die in a 
few hours from the time he was in apparent health. In other grave 
cases the temperature remains high, and rises instead of falls on the 
third or fourth day. The duration of the disease is from two to five or 
six days ; if a typhoid state develops, it may last ten days or two weeks. 

Complications are not common. Phlebitis and lymphangitis occur, 
and Guiteras says he has noticed hepatitis, insanity, and paralysis 
(probably from neuritis). Second attacks are extremely uncommon. 

Examination of Blood. The bacillus icteriodes is a slender rod 
from two to four micromes in length. It is ciliated and motile. By 
staining a drop of blood with Gram's method it is seen in more than 
half the cases. 

Serum Diagnosis. Woodson and the Archinards have found agglu- 
tination to take place in a large proportion of cases of yellow fever. 
The blood, taken as early as the second day, gave a prompt reaction in 
from 75 to 80 per cent, of all cases. Dilutions of 1 to 40 were used, 
but reaction took place in dilutions as low as 1 to 5. Pothier and 
Lerch report successfully upon this reaction. Cultures from the blood 
produce an organism which grows on ordinary media ; does not coagu- 
late milk, but ferments saccharine fluids. 

Inoculation. Inoculation of dogs and monkeys produces a clini- 
cal picture similar to the original infection. 

Diagnosis. Yellow fever is distinguished from pernicious malarial 
fever by the slow pulse, the characteristic facies, the early transient 
albuminuria, the deep jaundice, the absence of diarrhoea, the occur- 
rence of black vomit, the tendency to hemorrhage, and the clear mind. 

If it is not practical to make a diagnosis based upon an examination 
of the blood, the three important characteristics which Guiteras laid 
stress upon must be borne in mind in addition to the usual data secured 
for the purpose of determining the presence of an epidemic and conta- 
gious disease. The three diagnostic points of Guiteras are the facies, 
the albuminuria, and the slowing of the pulse, with continuance or in- 
crease of the fever. By these means the affection must be distinguished 
from dengue and from various forms of malarial fever, especially the 
aestivo-autumnal infections. 

Malta Fever. 

Malta fever is a remarkable infection which seems to prevail within 
the limits of the Mediterranean. It is an infection characterized by 

20 



306 



GENERAL DIAGNOSIS. 



gradual onset and by repeated remissions of the fever. The alternating 
febrile and afebrile periods which characterize the disease continue 
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THE DATA OBTAINED BY OBSERVATION. 307 

peculiar character of the temperature-range, which consists of intermit- 
ting waves or undulations of fever of a distinctly remittent type. 
These periods of fever last from one to three weeks, followed by an 
apyretic period or a period of abatement lasting from two to ten days. 
The daily temperature-range may be intermittent or remittent. The 
febrile course may continue six months or more. During this time 
patients grow more and more prostrated, become anaemic, and usually 
suffer from constipation. Profuse sweats attend the decline of the 
daily range, and in many instances we find enlargement of the spleen. 
Neuralgias occur in various parts of the body ; the joints become en- 
larged, and fibrous tissues may be the seat of inflammation. Hughes 
— who describes the disease most accurately — describes a malignant 
type lasting a week or ten days, and an undulatory type continuing 
for weeks or months. Indeed, the relapses are known to occur over 
a period of two years. The third is known as the intermittent type, 
in which there is a daily rise of temperature without other marked 
symptoms. The undulatory type is the most common variety. The 
infectious micro-organism is the micrococcus melitensis. 

Diagnosis. The occurrence of fever described above in the coun- 
tries bordering upon the Mediterranean, whether epidemic or endemic, 
should always suggest Malta fever. The possibility of its occurrence 
in other tropical countries, as in the islands of the Caribbean Sea, must 
not be forgotten. A positive diagnosis is made by exclusion of all 
forms of malaria by an examination of the blood, and of typhoid fever 
by finding the bacillus typhosus in the urine or stools of the suspected 
patient. The micro-organism has not been isolated from the blood, 
but the serum reaction is a valuable means of diagnosis. (See page 233.) 
This reaction is performed as in cases of typhoid fever. The culture 
must be carefully selected. With a 1 to 10 or 1 to 50 dilution aggluti- 
nation takes place when the serum of a patient with Malta fever is 
used. The serum of such a patient does not have any effect upon 
the typhoid bacillus nor upon other organisms. Aldrich states that 
the first reaction occurs about the fifth day. 

Gonorrhceal Infection. 

Although the infection is usually limited to the genito-urinary tract, 
it is well known that the gonococcus may enter the blood and infect 
tissues elsewhere, causing a local inflammation. We therefore see 
symptoms due to the primary infection ; symptoms due to the infection 
of the genito-urinary organs by direct continuity, and systemic infection. 
The primary infection involves the adnexae of the genital organs in the 
male and the female. Salpingitis, metritis, and ovaritis in females, 
with the occurrence occasionally of peritonitis, arise from spreading by 
continuity. In both sexes cystitis, ureteritis, and pyelitis occur. The 
infection is usually mixed. 

When the gonococcus invades the blood, symptoms of septicaemia or 
pyaemia arise. The infection may be rapid and fatal, and may termi- 
nate ten days after the primary lesion. The occurrence of such general 
infection is suspected when the history of the primary infection can be 



308 GENERAL DIAGNOSIS. 

secured, and in addition the micro-organism can be recovered from the 
blood, as was successfully done by Thayer. 

In other infections the joints become involved and we have the 
phenomena of gonorrhoeal rheumatism (see Joints), the course and 
symptoms of which are discussed elsewhere. Endocarditis may result 
from gonorrhoeal infection, and can only be distinguished from other 
forms of endocarditis by the history and the finding of micro-organ- 
isms in the blood. Myocarditis (Councilman) and pericarditis may 
also occur. 

Diagnosis. Thayer and Blumer and Thayer and Lazear have suc- 
ceeded in recovering the gonococcus from the blood in this form of 
septicaemia. The blood is withdrawn from the median basilic vein by 
a sterilized syringe. A large quantity is secured. It is mixed with 
melted agar and immediately plated. The medium should contain 
at least one-third blood. This is practically the medium which Wer- 
theim recommends. After forty-eight hours colonies appear half the 
size of a pin-head, granular, but with irregular borders. Cover-slip 
preparations of the colonies, if the case is gonorrhoea, will show the tinc- 
torial and morphological characteristics of the gonococcus. (See Plate 
III., Fig. 3, B. The diagnosis is further established by finding the 
gonococcus in any purulent discharge, as of the urethra or vagina. (See 
Chapter XXI. — Exudations, etc.) 



CHAPTER XX. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 

FEVER. THE INFECTIOUS DISEASES. 

Infections Recognized by the Examination of Excretions and 
Secretions or by the Products of the Infectious Inflammation. 

The following infections are disclosed by the examination of the 
products of the infection found in the inflammatory areas (pus) ; in 
the excretions and secretions of the body ; in the sputa ; in the vom- 
itus ; in the faeces or in the urine. The reader should refer to the 
sections describing the method of the examination of pus, sputum, 
and secretions bacteriologically. They are as follows : Erysipelas, 
pneumonia, tuberculosis, influenza, cerebrospinal meningitis, diphtheria, 
septico-pycemia, glanders, cholera Asiatica, dysentery, bubonic plague, 
leprosy, actinomycosis, tetanus, trichinosis. 

Erysipelas. 

The fever of this infection, particularly in a first attack, is very 
marked. It rises suddenly to a considerable height and may antedate 
the eruption. It resembles the course of a pneumococcus infection. 

It is an acute, specific, contagious, and infectious disease, character- 
ized by a sudden onset, with a bright-red eruption, which usually begins 
on the face near the nose or mouth and spreads over the entire face 
and scalp. It is attended with burning heat of the skin and great dis- 
figurement from swelling. 

The specific cause of erysipelas is the streptococcus erysipelatosus. 
It is carried to a slight extent by the air, and still more in the dis- 
charges, especially those of the nose. Repeated attacks occur in per- 
sons with chronic nasopharyngeal catarrh, carious teeth, or a sinus. It 
is apt to attack persons with open wounds (surgical erysipelas), and 
puerperal women, producing in these cases sloughing and septicseinia. 

One attack does not protect against another ; on the contrary, if there 
is any focus in which the streptococci linger, one attack actually pre- 
disposes to another. 

The period of incubation is usually from three days to a week. On 
close inquiry a history of sore-throat and some enlargement of the 
cervical lymphatics is usually found to precede an attack of facial 
erysipelas. The invasion is sudden and is marked by chill. The tem- 
perature rises to 104° or 105°, and in the next two or three days may 
rise still higher. 

Coincidently with the rise in temperature the portion of the skin to 
be affected burns, tingles, is tender to the touch, and may be seen to be 



310 GENERAL DIAGNOSIS. 

reddened. The redness increases in intensity and extent, while the 
skin is swollen and slightly oedematous. The part of the face to be 
affected is usually the cheek in close proximity to the nose, less fre- 
quently near the month and ear. Vesicles and blebs often form when 
the inflammation is very intense. The redness disappears upon press- 
ure, but quickly returns ; sometimes it has a dusky, purplish hue. 

A marked characteristic of the disease is its tendency to spread. In 
ordinary cases it involves one cheek, eyelid, and ear, and travels across 
the bridge of the nose to the other side. The inflammation is most 
intense when it is spreading ; the advancing margin is raised, tense, 
and brawny ; the line is thus sharply drawn between healthy and in- 
flamed tissue. The loose tissue about the eyes swells enormously, both 
eyes are closed, the entire face swollen, red, and disfigured with vesi- 
cles and blebs here and there. Curiously the chin escapes. The red- 
ness and swelling begin to subside in the part first attacked, before the 
process has reached its height on the opposite side. As a rule, facial 
erysipelas does not extend beyond the face, the scalp and neck being 
spared. The scalp, however, is more frequently affected than the 
neck ; occasionally erysipelas leads to extensive cellulitis of the scalp, 
with the production of a septic constitutional condition and much 
local sloughing. The submaxillary glands are more or less enlarged, 
sometimes so much so as to prevent the taking of solid food. 

When on the body the eruption spreads over a greater extent than 
when primary on the face, hence its name, " the red runner." It may 
pass from the heel to the thigh, and over the trunk, lasting for weeks. 

While the erysipelas is extending the fever continues, and is some- 
times alarmingly high. The pulse is frequent and soft. Leucocytosis 
is present. Nocturnal delirium is not uncommon in severe cases, and 
sometimes nausea and vomiting are frequent. The bowels are usually 
constipated. The urine is high-colored, frequently contains a small 
amount of albumin, and actual nephritis sometimes occurs. 

In favorable cases of facial erysipelas the process is at an end in 
a week or less. It may be prolonged to two weeks, subsiding by crisis 
or lysis, and convalescence is usually rapid. The vesicles or bullae dry 
up into yellowish crusts and the epiderm is shed in large or small 
pieces according to the intensity of the process. 

Pneumonia and nephritis are the most frequent complications. Men- 
ingitis, pericarditis, and endocarditis also occur. Erysipelas may extend 
inward and involve the fauces, pharynx, and larynx, producing oedema 
and death from suffocation. 

Sequelae. If the scalp has been involved the hair falls out. The 
cervical adenitis may result in abscess ; chronic nephritis may result. 
Otitis media occurs occasionally, and so do keratitis and abscess of the 
eyelids. 

On the other hand, erysipelas is credited with causing the disappear- 
ance of lupus, chronic eczema, and sarcomata. 

Diagnosis. Bacteriological Diagnosis. Examination of pus 
or discharge from the nose or thorax will disclose the presence of the 
streptococcus. (See Plate VII., Fig. 1, and Chapter XXI.) 

Herpes zoster of the face and forehead is distinguished from erysipelas 



THE DA TA OBTAINED B Y OB SEE VA TION. 31 1 

by the fact that vesicles appear first, followed by erythematous redness, 
and that they are limited by the median line, and are preceded and 
accompanied by sharp neuralgic pain, whereas erysipelas affects both 
sides of the face, and vesicles appear at the height of the disease ; the 
pain is much less in erysipelas. It is distinguished from dermatitis of 
various kinds mainly by the sharper febrile reaction, the raised border 
of the eruption, which begins on one side and spreads to the other. 
Erysipelas is rarely equally intense upon the two sides. Dermatitis 
frequently is. The latter often exhibits a rough surface, whereas, until 
vesicles appear, erysipelas is smooth and shiny. 

Chronic erythematous eczema occurs in the middle-aged and old per- 
sons, is afebrile, accompanied by little swelling but a great deal of 
itching, and runs a slow course. 

Lobar Pneumonia. 

The Pneumococcus Infections. In typical cases of the infection we 
are about to consider the course of the fever is of great diagnostic sig- 
nificance. Its sudden rise to a great height, preceded by a rigor, is of 
itself suggestive. During the succeeding days of the disease the morn- 
ing and evening temperature varies but little. When associated with 
hurried respiration and the intoxication symptoms attending this infec- 
tion, even though no physical signs are present in the lungs, pneumonia 
can reasonably be suspected. The termination of the febrile course is 
characteristic of the infection. The sudden fall to normal or a subnor- 
mal temperature — known as the crisis — brings to an abrupt end the 
usually alarming symptoms. 

Acute pneumonia, croupous or lobar pneumonia, is an infectious 
inflammatory disease excited by the micrococcus lanceolatus (diplococ- 
cus pneumoniae, pneumococcus) involving the vesicular structure of the 
lungs, and followed by choking of the alveoli with the products of 
inflammation ; it is attended by severe constitutional symptoms due to 
the toxines of the infecting organism. 

Symptoms. Mode of Onset. The invasion of pneumonia is usually 
sudden, and is marked by a chill. The temperature rises rapidly, and 
may reach 104° or 105° in the first twelve hours after the chill. With 
the fever, the patient complains of severe headache and pain in the 
side, and has a short, quick cough and sometimes vomiting. The pulse 
is moderately accelerated, and the respiration either is or soon becomes 
very frequent. The face is apt to be flushed, and there may be a circum- 
scribed red spot on the cheek. The skin is hot and dry. On physical 
examination, within the first twenty-four hours, a small patch of con- 
solidation is detected, which may subsequently extend over a large 
area. 

While this is the picture of an ordinary pneumonia in its early stage, 
all cases are by no means so clear. In some the course resembles that 
of a general fever in which the pulmonary disease is a local manifesta- 
tion. In such cases there may be prodromata, consisting of headache, 
general malaise, a slight bronchitis, and digestive disturbance. Then 
follows the chill. Central pneumonia. The fever may be high for 



312 GENERAL DIAGNOSIS. 

several days before there is any discoverable consolidation of the lungs , 
and during this time cough may be wholly, or almost wholly, absent. 
The respirations increase gradually in frequency, and finally a Avell- 
marked pneumonia can be made out. It is customary to account for 
these cases by the supposition that pneumonia developed in the interior 
of the lung and consolidation gradually extended to the surface. In 
some cases the patient presents no more definite symptoms for three 
or four days than high fever, intense headache, and moderately accel- 
erated respiration. 

Later Stages. At the end of forty-eight hours, or, at the most, 
of four days, the patient is found lying in bed in the dorsal position, 
or on the affected side. The face is flushed, and countenance anxious, 
the respiration hurried, the alse nasi play vigorously. The tempera- 
ture varies little from the first day's rise ; the chest pain has subsided, 
and the short, dry cough is now attended by viscid expectoration. The 
respiration continues hurried, the pulse full and bounding. During 
this time the physical signs of consolidation continue and increase. 

After a period of five to ten days the termination takes place by 
crisis, the pain in the chest abates, the cough becomes looser, and the 
expectoration more free, but the other symptoms persist. In addition, 
in some cases, delirium occurs, the pulse softens and becomes dicrotic, 
the urine becomes albuminous. 

Respiratory Symptoms. Chest-pain, cough, hurried respiration 
of a peculiar type, and expectoration are characteristic. The chest- 
pain is sharp and stabbing or lancinating. It is increased by breath- 
ing. It is seated about the nipple or in the axillary region, at the 
angle of the scapula or below the diaphragm. Its seat always indicates 
the side affected. Cough is short and dry, smothered and painful ; 
it soon becomes softer and painless as the expectoration becomes free. 
It may be absent in the feeble, in the aged, in alcoholic subjects, or in 
persons with brain disease, including insanity. 

Characteristic symptoms of pneumonia are the increased frequency 
and the type of the respiration. The rate in adults reaches 40, 50, or 
even 60 per minute, and in children 80 and 100 are not very un- 
common. 

The pulse, on the contrary, does not increase in frequency in the 
same proportion ; hence, the normal ratio of respiration to pulse of 1 
to 4 ceases, and becomes 1 to 3 or 1 to 2. 

Inspiration is short, expiration quick and often attended by an expi- 
ratory noise or grunt. The long pause may take place after inspira- 
tion instead of expiration. In children both are so short that unless 
the epigastrium is inspected it may be difficult to distinguish the two. 

In ordinary cases which run a normal course the cough is followed 
by expectoration, which is at first viscid mucus, but gradually becomes 
reddish-brown from admixture of blood — the rusty sputum of pneu- 
monia. This sputum is characteristic, almost pathognomonic. It is 
expelled with difficulty from the mouth, clinging to the lips or to the 
mustache. It cannot be removed from the spit-cup by turning it 
upside down. It continues to be rusty, and as the crisis approaches 
becomes purulent and is discharged with ease. In typhoid pneumonia 



THE DATA OBTAINED BY OBSERVATION. 



313 



it looks like prune-juice (See Sputum.) It contains blood, alveolar 
epithelium, the specific micrococcus, and later pus and small fibrinous 

casts. 

Fjg. 74. 





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Pneumonia. Sudden rise ; termination by crisis. Pseudo-crisis on eighth day. 



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Pneumonia from first day. Pseudo-crisis on fourth day. Crisis began on fifth. 



314 GENERAL DIAGNOSIS. 

The Fever. The chill that precedes the fever is pronounced and 
is always a warning to look for a pulmonic inflammation. In children 
a convulsion is rarely absent in frank pneumonias. During its occur- 
rence the body-temperature rises. In twelve hours it reaches 104° to 
105°. (See Figs. 74 and 75.) It remains at this point, obeying the 
laws of diurnal variation. The hot, dry skin, the parched lips, the dry 
tongue, the thirst, the anorexia, the hurried breathing, the occasional 
delirium, the loaded urine attest its presence. At the end of the third, 
or more frequently the fifth, seventh, or ninth day, crisis takes place ; 
the fall is abrupt, and the normal or a subnormal temperature may 
be reached in from five to fifteen hours. Pseudo-crisis, as the accom- 
panying chart indicates, may precede the true crisis by twenty-four or 
forty-eight hours. The decline may take place by lysis, however. Pro- 
tracted fever indicates delayed resolution or the occurrence of a compli- 
cation. 

Cerebral Symptoms. In some cases, especially in children, the 
onset of the disease may be marked by a convulsion. This is said to 
occur more frequently in apical pneumonias than in pneumonias of the 
base. Headache and delirium are so pronounced in some cases as to 
simulate meningitis. This is most likely to be the case in severe apical 
pneumonia in children, and in double pneumonia either in children or 
in adults. 

Delirium may occur during the height of the fever, and occasionally 
is maniacal. Nocturnal delirium may be a constant symptom in very 
grave cases. In drunkards it may simulate delirium tremens, and 
may be pronounced, without much fever. In the later stages of grave 
or fatal cases a low form of delirium, with a tendency to coma, is 
common. 

The Heart and Pulse. The pulse is small at the time of the chill, 
but becomes full and bounding during the fever ; later it may become 
dicrotic. The pulse-respiration ratio has been referred to. The pulse 
varies in frequency and in character with the type of the disease. In 
healthy adults it is rarely over 110. In the debilitated it may be very 
frequent, small, and feeble ; in the aged, frequent and dicrotic. Exten- 
sive consolidations reduce the amount of blood in the general circula- 
tion, cause rapid action of the heart and a small pulse, and favor death 
with the heart in asystole. 

The heart-sounds are clear. A murmur low in pitch is often heard 
in the mitral and pulmonary areas. The left ventricle acts forcibly. 
The pulmonary second sound is accentuated. If dilatation and failure 
of the right heart takes place, the area of dulness may extend beyond 
the right edge of the sternum, an epigastric impulse be noted, tur- 
gescence of the veins in the neck become marked, but, above all, the 
previously accentuated pulmonic second sound may become weak or 
disappear. 

Gastro-intestinal Symptoms. Vomiting frequently occurs in chil- 
dren at the onset, and both in them and in adults may persist and mask 
pulmonary symptoms. The appetite is lost. The tongue is furred. 
It may become dry and brown. The bowels are constipated except 
when complications occur. The spleen is enlarged. The vomiting and 



THE DATA OBTAINED BY OBSERVATION. 315 

epigastric pain may be so pronounced as to mask the pulmonary symp- 
toms. The occasional presence of jaundice has caused it to be mistaken 
for hepatitis, congestion of the liver, and even for gallstones. I saw 
a case of pneumonia, said to be appendicitis and peritonitis because of 
the characteristic pain, colic, and vomiting, followed by great abdomi- 
nal tenderness in the upper abdomen. 

The Blood. Leucocytosis is a marked accompaniment of pneumonia, 
especially in cases ending favorably. The white cells may be increased 
from 12,000 to 40,000. They fall with the crisis, or probably a day 
after the termination of the fever. In malignant forms there may be 
no leucocytosis. Increase in the fibrin network causing the " buffy 
coat " of older writers is commonly seen. 

Cutaneous Symptoms. Herpes on the lips, the nose, or the geni- 
tals is of common occurrence. Sweating occurs with the crisis, or if 
heart failure is imminent. 

The Urine. The urine is scanty and high-colored, and may contain 
a small amount of albumin. In some cases the chlorides are found to 
be absent. This is determined by acidulating the urine with a drop 
or two of nitric acid, and then adding one or two drops of a 10 per 
cent, solution of silver nitrate. If chlorides are present a heavy white 
cloud of chloride of silver is thrown down. The chlorides are not 
invariably absent, or even diminished in pneumonia, hence their reap- 
pearance, which is said to indicate beginning convalescence, loses its 
value as a prognostic sign. 

Physical Signs. (See Diseases of the Lungs, Plate XIX.) Con- 
solidation. Diminution in the amount of air, increase of solid con- 
tents. On inspection, diminished movement. If extensive consolidation, 
enlargement of the affected side. On palpation, inspection confirmed 
and increased vocal fremitus discovered. Both are more marked at the 
height of consolidation. Percussion. In first stage, impaired resonance 
or Skodaic resonance. In stage of hepatization, dulness or flatness, but 
without any wooden quality or marked resistance. 

Auscultation. In the early stage, that of congestion, the respira- 
tory murmur is suppressed and crepitant rales are heard at the end of 
inspiration. On full inspiration or after cough a broncho-vesicular 
respiration is brought out. When consolidation has taken place the 
respiratory murmur is bronchial. Rales, if present, are moist subcrep- 
itant rales from associated bronchitis, or a few crepitant rales may still 
persist, and a friction-sound be heard. 

When resolution sets in the crepitant rale reappears, quickly followed 
by moist subcrepitant rales, heard both on inspiration and expiration, 
while dulness gradually yields to impaired resonance. The respiration 
loses its bronchial character and again acquires a vesicular element 
before becoming completely normal. It may be a week or two, or 
many months, even in uncomplicated cases, before the percussion-note 
becomes perfectly clear, and rales wholly disappear. 

The physical signs are modified by the intensity of the inflammation 
in the lung structure and by the pleural complications. In massive 
pneumonia, for instance, the auscultatory signs are absent. On percus- 
sion, the lung is absolutely flat. There is no fremitus or tubular breath- 



316 GENERAL DIAGNOSIS. 

ing. The physical signs resemble those of pleurisy with effusion. In 
the central pneumonia the physical signs may be delayed until the third 
or fourth day. A few rales or febrile breathing over a small area may 
be the only indication of a possible lung process. In the aged the 
physical signs are obscure. In patients with laryngeal disease or marked 
obstruction in the nasopharynx the physical signs may be indefinite. 
Bronchial breathing may not be heard unless the patient takes a full 
breath or coughs. In this class of cases, as well as those with feeble 
respiratory movement, as the aged, the Aveak, and those suffering from 
some other disease, as tuberculosis, the physical signs are not made out 
because of the deficiency of respiratory movements. The indefiniteness 
of the physical signs makes the diagnosis all the more difficult, because 
it is this class of subjects in which the general symptoms of infection 
are very slight. Increased respiration may be the most suggestive 
sign. Slight elevation of the temperature and more or less stupor may 
be the only other clinical symptoms. 

Duration and Course. The duration of the disease is from one to 
two weeks. It may subside by crisis on the third, fifth, seventh, or 
ninth day, or gradually by lysis. Crisis is marked by a critical sweat, 
a copious discharge of limpid urine, or sometimes by a few loose move- 
ments of the bowels, accompanying a fall of temperature to or below 
normal. 

Instead of clearing up, the pneumonia may progress to suppuration, 
abscess, or gangrene. These conditions can be made out by the char- 
acter and range of temperature, the general condition of the patient, 
the sputum, and the physical signs. Termination in abscess or gan- 
grene is rare. 

In cases proceeding to a fatal issue the strength fails, respiration 
becomes more labored, and expectoration increasingly difficult. The 
number of respirations often diminishes, but the pulse continues fre- 
quent and often becomes small and irregular. Physical examination 
shows diffuse bronchitis with oedema. The heart's action is irregular 
and rapid. The sounds are weak and feeble ; the first becomes short 
and snappy like the second, and later both are weak or indistinct. Death 
may occur abruptly from convulsion, or more frequently from asphyxia, 
due to oedema of the lungs, which in turn sets in on account of weak- 
ness of the heart or the development of heart-clot from cardiac asystole. 

Varieties. Migratory pneumonia. Sometimes, with the reappear- 
ance of abundant rales and increased expectoration, the fever continues 
high, or, if the temperature has fallen to normal, again rises, the 
patient is disinclined to take food, has a dry, brown tongue, and is often 
delirious. In such cases the pneumonia is probably extending in the 
lung already involved, or has attacked the other lung. 

Typhoid pneumonia is an unfortunate name for an adynamic form of 
the disease with typhoid symptoms. If it arises in the course of or 
complicates low fevers, it is usually of the typhoid type ; but it occurs 
also in those much exhausted, in depraved health, or exposed to unhy- 
gienic surroundings. It is found also in cases of septicaemia, in Bright' s 
disease, in drunkards, and in the negroes in the southern part of the 
United States. 



THE DATA OBTAINED BY OBSERVATION. 317 

The characteristic features of this form of pneumonia are the great 
physical prostration and the weak heart-action. The fever is high, the 
respiration and pulse frequent, and delirium and vomiting are more 
frequent than in the ordinary form. The skin sometimes has a dusky 
hue ; the tongue is heavily coated, or may be dry and brown, and 
sordes collect on the teeth. The sputa may be rusty, and sometimes 
pure blood is expectorated. The disease may prove fatal rapidly, or 
may linger for a long time, the patient only gradually coming out of 
a low typhoid state. It is always dangerous. 

Bilious pneumonia is the name given to a type of pneumonia occur- 
ring in persons who are already suffering from malarial poisoning. 
The initial chill lasts longer, and the pain in the side, from coincident 
pleurisy, is more marked that in ordinary pneumonia. The fever is 
more remittent, and jaundice and vomiting are present. 

Pneumonia in infants is characterized by nervous symptoms. Re- 
peated convulsions and active delirium may be most pronounced, fol- 
lowed by torpor and coma. There is no sputa and but little cough. 
The apex of the lung is affected. 

Pneumonia in the aged is characterized by latency of symptoms. 
There is but little cough and expectoration. A tendency to the typhoid 
state, however, is pronounced. The physical signs are obscure. 

Pneumonia in alcoholic subjects also develops insidiously and may be 
masked by the symptoms of delirium tremens. The temperature may 
be the only indication of infection, as there is no pain, no cough, no 
expectoration, and no dyspnoea. 

Pneumonia with Other Infections. The staphylococcus and strepto- 
coccus pyogenes, the colon bacillus, and the bacillus pneumoniae (Fried- 
lander) are often found with the pneumococcus, and may predominate, 
inducing a mixed infection. The micro-organisms which cause diph- 
theria, typhoid fever, influenza, and the plague may cause a pneumonia 
which resembles that of lobar pneumonia in the extent of the consoli- 
dation. The micrococcus lanceolatus is found in increased numbers in 
the sputum of these cases. There is not the same intensity of pulmo- 
nary symptoms, however. The respirations are not so hurried. The 
physical signs, while extensive, are obscure, and indicate rather a heavy 
lung (congested) than one greatly consolidated. There is impaired reso- 
nance, feeble breathing, and a few rales in a large number of cases. 

It is this form of lobar pneumonia which it is difficult to distinguish 
from bronchopneumonia or catarrhal pneumonia — an infection which 
usually begins in the upper air passages. This form of local infection is 
considered in the chapter on diseases of the lungs. 

Diagnosis. The diagnosis is based upon the aggregation of special 
symptoms. The mode of onset, the chill, the course of the fever, the 
pain in the chest, the cough, the peculiar expectoration, the dyspnoea, 
the abnormal pulse-respiration ratio, the peculiar character of breath- 
ing, the physical signs, and leucocytosis are the phenomena of the symp- 
tom-complex. It must be remembered that in children, in the aged, in 
drunkards, in cases of chronic disease, the type is different. In drunk- 
ards cerebral symptoms are more marked. In children the cerebral 
symptoms are more prominent, the expectoration often absent. In the 



318 GENERAL DIAGNOSIS. 

aged, the cough, the expectoration, and the fever are not pronounced ; 
the former may be absent ; the onset is insidious. The same onset and 
course occur in wasting diseases, as cancer, phthisis, Bright' s disease, 
diabetes, and organic heart disease. In this class of cases a small patch 
of pneumonia, difficult to determine on physical examination, may be 
attended by the gravest general symptoms. In all of the above cases, 
if there is fever without cause, although no pulmonary symptoms are 
present, the lungs must be examined repeatedly. In many such cases 
the physical signs are obscured because respiratory action is enfeebled 
by the primary condition. 

Pneumonia must be distinguished from other acute inflammatory 
affections of the lung and pleura and from acute tuberculo-pneumonic 
phthisis. The evidence for each is considered in the respective sections. 
The presence of leucocytosis serves to distinguish it from acute tubercu- 
losis and from typhoid fever, meningitis, and influenza. To distinguish 
pneumonia from pleurisy with effusion, the aspirator may be used. 

Bacteriological Diagnosis. Staining and microscopical exami- 
nation of the sputum reveal the characteristic micro-organism. Care 
must be taken to secure the sputum from the lung. By inoculation of 
rabbits with the sputum the disease is readily reproduced. The organ- 
ism is not readily found in the blood. (See the Sputum.) 

Pneumonia may be distinguished from cerebrospinal meningitis by 
the results of spinal puncture alone ; from acute tuberculous pneumonia 
by the examination of the sputum. The diagnosis in the latter instance 
may be postponed, as tubercle bacilli are sometimes not found until the 
tenth or twelfth day. (See Tuberculosis.) Typhoid fever sometimes 
resembles pneumonia, and must be distinguished after the first week 
by the results of serum diagnosis. 

Pneumococcus Septicaemia. The account we have just given of 
pneumonia represents but one phase of the pneumococcus infection. 
This infection may be attended, by very grave symptoms, especially 
those of a toxic nature, with but little if any involvement of the lung 
tissue. It is well known that we may see the chill, fever, rapid pulse, 
and hurried respiration with but little evidence of consolidation in the 
lung, but with nervous symptoms paramount. Delirium, stupor, coma 
with the phenomena of the ataxic or the typhoid state may prevail. (See 
pages 199 and 200.) In the ataxic state the symptoms resemble those 
of mania. In the typhoid form they are not unlike those of uraemia. 
In either instance death ensues in coma or from heart failure with its 
attending symptoms. Preceding the cardiac failure the urine is dimin- 
ished in amount and the secretions generally suppressed. 

In other forms of this infection the localization of the process is in 
the pleura, as in empyema, in the pericardium, in the endocardium, 
and in the cerebral meninges. Pneumococcus inflammation of these 
structures is very common. It may develop at the same time that the 
lungs are affected, independently of the process in the lungs, or subse- 
quent to it. These forms will be considered in a discussion of the 
various local inflammations just referred to. 

It is important to remember that in pleural, pericardial, and cerebro- 
spinal infections the nature of the infection can be determined by aspi- 



THE DATA OBTAINED BY OBSERVATION. 319 

ration and bacteriological examination of the fluid removed from the 
respective serous cavity. The pneumococcus infection can be positively 
diagnosticated in this manner. 

These complications, which occur in the course of the disease, modify 
the clinical picture and obscure the diagnosis. 

Tuberculosis. 

The infection discussed in this section prevails to a greater degree 
than that of all the others combined. In some forms, as pointed out 
in the clinical description, fever is one of the gravest symptoms. In 
other forms the febrile process may not be pronounced. It must be 
remembered that the fever may be due to the specific micro-organism 
or its toxin, or it may be due to a mixed infection. Staphylococcus 
and streptococcus infections are common attendants upon the tubercu- 
lous infection. This secondary infection may disappear or may become 
the most prominent infection. In many instances a terminal infection 
ensues, causing mortal symptoms. Infection by the pneumococcus is 
the most common of these terminal infections. (See page 228.) 

Tuberculosis is an infectious disease, the course of which may be 
acute or chronic. It is caused by the bacillus tuberculosis. This 
micro-organism sets up a specific inflammation characterized by the 
development of nodules or tubercles, or by a diffuse growth of tuber- 
culous tissue. Either anatomical product may undergo caseation or 
sclerosis, and in either instance ulceration or calcareous degeneration. 

Invasion of the body by the micro-organism may give rise to general 
infection, with an eruption of miliary tubercles in most of the organs 
and structures of the body, or to a local infection. General tubercu- 
losis is acute ; local tuberculosis may be acute or chronic. In acute 
tuberculosis the serous membranes, the lungs, liver, kidneys, lymphatic 
glands and spleen, the bone-marrow, and choroid coat of the eye may 
be invaded in whole or in part. In chronic tuberculosis the lymph- 
glands, the lungs, the serous membranes, the tissues and organs of the 
alimentary canal, the liver, the organs of the genito-urinary system, 
and the brain and cord are individually invaded. 

Diagnosis. The diagnosis of any form of tuberculosis is aided by 
the determination of the chief factors in its etiology, where this is 
possible. 

Bagtekiological Diagnosis. First. The discovery of the bacillus 
tuberculosis in any inflammatory area, or any product of inflammation, 
as serum, blood, pus, or the secretion from any gland or mucous mem- 
brane invaded by the disease, establishes at once the diagnosis of this 
condition. The method of determining the presence of this micro- 
organism is fully detailed in the various descriptions of tuberculosis in 
the discussion of local diseases, and in the accounts of the examination 
of the sputum and of exudations and transudations. Inoculation of 
inflammatory products, as of a gland or of fluid which has been sedi- 
mented, is a positive mode of diagnosis. Guinea-pigs are selected for 
this purpose. 

Second. As tuberculosis is an infectious disease, discovery of the 
infection is an aid in the diagnosis. Infection takes place by means of 



320 GENERAL DIAGNOSIS. 

the inhalation of the sputum or other secretions, which when dry float 
about in the air. It implies in a measure more or less contact with 
individuals previously infected. In rare cases such contact is produc- 
tive of the disease by means of direct contagion. The second source of 
infection is the food-supply. This may occur from the consumption 
of milk secured from a cow infected with tuberculosis. The eating of 
meat of tuberculous animals may possibly lead to infection. Direct 
inoculation is another but rarer source of infection. This usually 
occurs accidentally only. 

Third. It is possible that tuberculosis may be inherited. A more 
prominent etiological f actor , which aids in the diagnosis of the disease, 
is the presence of a certain type of structure which is a marked heredi- 
tary characteristic in families, on account of which feeble resistance is 
offered to the invasion of the tubercle-bacillus. The phthisical and 
phthisinoid chest which belongs to this type has been described else- 
where, and the tuberculous and scrofulous states have been outlined. 
(See page 67 and Part II., Chapter II.) These anatomical conditions, 
which are inherited, undoubtedly favor the development of tuber- 
culosis. 

It is a mistake to lay much stress in the diagnosis of tuberculosis 
upon the age or the occupation of the individual. Tuberculosis may 
occur at any age. It is true, however, that at certain periods of life 
the tubercles are distributed more commonly in one group of organs, 
while in other periods they affect another group. Lymphatic, joint, 
and meningeal tuberculosis is most common in the first decade of life. 
The mesenteric glands are particularly open to invasion at this period. 

The diagnosis of tuberculosis, whether local or general, is further 
aided by a complete knowledge of the phenomena that attend the 
entrance of the virus into the body and the mode of diffusion through- 
out the body after infection has taken place. The phenomena at the 
point of entrance of the micro-organism are nearly always distinct. 
The general invasion is associated with symptoms like those of specific 
fevers. The local secondary effects upon the tissues are always decided. 
It must be borne in mind that after the exposure, which may lead to 
infection, either an acute form of tuberculosis of a general character 
may be set up, with or without marked local symptoms, or acute local 
tuberculosis alone may arise. In local tuberculosis the disease is con- 
fined to one organ or to the lymphatic glands and the organs in the 
lymphatic distribution, as the bronchial glands, which are primarily 
affected, and to the lungs. In these structures the entire process of 
nodular formation, caseation or sclerosis, ulceration or calcification, 
may take place. The disease remains primarily local. On the other 
hand, it may be spread by continuity of structure through the lymph- 
atics throughout the remainder of the organ affected, leading to its 
ultimate destruction and the death of the patient ; or general infection 
of the system may take place from the primary local area. The pri- 
mary seat of infection may be the lungs, the larynx, the alimentary 
tract, or the genito-urinary organs. Primary tuberculosis of the serous 
membranes, of the lymph -glands, of the bones and joints, may take 
place. 



THE DATA OBTAINED BY OBSERVATION. 



321 



The symptomatology and diagnosis of the various forms of tubercu- 
losis are detailed in the section devoted to the special diseases of the 
various organs of the body. 

The Tuberculin Test. The physical signs and clinical symptoms 
may point to an inflammatory process in one of the many structures of 
the body which may be invaded by tubercle bacilli. On the other 
hand, failure in health, loss of weight, anaemia, and moderate fever may 
alone occur. The nature of the inflammatory process may be obscure. 
To determine more accurately whether the inflammation is tuberculous 
or not, or the "decline" due to tuberculosis, we can resort to the use of 
tuberculin. Since the researches of Koch, who introduced tuberculin 
as a remedy in tuberculosis, he himself as well as a number of other 
observers, has employed this preparation to determine the presence of 
tuberculosis in the body. In this country Trudeau has been the earliest 
and most earnest exponent of this means of diagnosis. After the injection 
of tuberculin a group of phenomena follows, known as the tuberculin 
reaction, if tuberculosis existed anywhere in the body. It was thought 
the occurrence of this reaction was necessary to bring about a cure. 
As a therapeutic measure its value has not been upheld by experience. 
The invariable production of the reaction has led it to be used as a 
diagnostic medium. 

Phenomena of Eeactiox. About twelve hours after the injec- 
tion of tuberculin the temperature rises rapidly. In the course of a 
few hours it has risen two or three degrees. This elevation of tem- 



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Typical reaction with tuberculin. 



perature is attended by malaise, pains in the head, back, and legs, and 
sometimes nausea or vomiting. The maximum temperature is main- 
tained for two or three hours, and then a gradual decline to the normal 
takes place. The normal temperature is reached in from twenty-four 

21 



322 GENERAL DIAGNOSIS. 

to thirty-six hours. The whole period of the reaction, from the time of 
the injection until the termination of the fever, is about forty-eight 
hours. With the fall of temperature to normal the constitutional 
symptoms subside. The accompanying chart (Fig. 76) shows the 
course of the fever in a typical reaction. 

Method. Twenty-four to forty-eight hours preceding the test the 
patient's temperature should be taken every two hours to determine 
the range at this period of the disease. The injection should be made at 
a time when the reaction could be observed — i. e., during the period 
of normal or subnormal temperature. This, of course, can only be 
selected if the temperature of the disease is intermittent. The hour of 
day selected to inject the tuberculin should be such that the reaction 
may be conveniently observed during the waking hours of the patient. 
Bedtime or the early morning hours are the most convenient. 

The site of the injection is not material. Usually the interscapular 
space is selected. The amount of tuberculin employed is of the greatest 
importance. The initial dose should never exceed five milligrammes, 
and it is better to use less than this, and an increasing quantity in- 
jected every second or third day. The maximum dose should not ex- 
ceed ten milligrammes. For children one-twentieth to one-tenth of a 
milligramme may be the initial dose. The crude tuberculin should be 
diluted at the time it is used with 1 to 2 per cent, solution of carbolic acid. 

At the point of injection a little redness and infiltration, with tender- 
ness to the touch, is observed. This local reaction may also be seen at 
the site of former negative injections when the larger dose produces 
reaction. In pulmonary tuberculosis in which physical signs are 
obscure some auscultatory phenomena which were previously absent 
may be found during the period of a reaction. This test also enables 
one to detect tuberculosis in the pleura, pericardium, peritoneum, 
genitourinary tract, and lymphatic glands, the meninges, bones, and 
the skin. The test is of special value in cervical adenitis. 

It must be remembered that a negative result with large doses of 
tuberculin is of more value than a positive one. In the former instance 
one can affirm that tuberculosis is absent, as well as that there is no 
old focus in any of these organs. It must also be remembered that 
the test should only be employed after all other means have failed to 
make a positive diagnosis. 

Acute miliary tuberculosis has been spoken of elsewhere. (See Part II., 
Chapter II.) Its course may resemble typhoid fever, septicaemia, or 
malignant endocarditis. It usually develops in the course of tubercu- 
losis in some other organ of the body. The typhoid form has been 
described in the section indicated. It must not be forgotten that the 
diagnosis is rendered positive by the demonstration of the presence of 
tubercle-bacilli in the blood, or of the occurrence of choroidal tubercles 
in the eye-ground. Another form is attended by marked pulmonary 
symptoms. This is the type seen in the bronchial pneumonia that occurs 
in children following measles and whooping cough. (See Catarrhal Pneu- 
monia.) Of the pulmonary symptoms dyspnoea is the most prominent. 
Cyanosis is marked. The physical signs are not prominent, and may 
be those of bronchitis alone. Although there is impaired resonance 



THE DATA OBTAINED BY OBSERVATION. 



323 



at the base of the lungs, areas of hyper-resonance are observed above and 
in front of the chest. Collapse of the lung may cause tubular breathing. 
The temperature rises to 102° or 103°. An inverse type may be seen. 

The diagnosis of acute tuberculosis is determined by the history of 
infection from extraneous sources or from local tuberculosis in some 
portion of the body, and by the presence of bacilli. 

The following conditions should point to the possibility of chronic 
tuberculosis in some portion of the body : (1) Emaciation, not otherwise 
explained ; (2) chlorosis or anaemia ; (3) weakness without cause ; (4) 
fever — the temperature should be taken every two hours during night 
and day ; (5) causeless sweats ; (6) gastro-intestinal catarrh ; (7) morn- 
ing nausea ; (8) signs of local inflammation in some organ of the body. 

Influenza. 

High temperature out of proportion to the local signs of inflamma- 
tion in the lungs or other structures characterizes this infection. The 
fever may be continuous, remittent, or intermittent. 



Fig. 77. 






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324 



GENERAL DIAGNOSIS. 

Fig. 78. 



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Influenza— intermittent type. (Wilson.) 
Fig. 79. 



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Influenza— remittent type. (Wilson.) 



THE DATA OBTAINED BY OBSERVATION. 325 

Influenza is a specific contagious febrile disease, occurring in wide- 
spread epidemics, having a very short period of incubation, and charac- 
terized by great prostration, marked nervous symptoms, and catarrhal 
inflammation of the respiratory or gastro-intestinal tracts, or both. 
There is great liability to relapse, and to complications, which are gen- 
erally pulmonary or nervous. 

The disease generally begins with the ordinary symptoms of coryza ; 
but the headache over the eyes and root of the nose is more severe, and 
may be so agonizing as to mask all other symptoms. The lacrymation, 
rhinitis, and tormenting cough are all usually worse than in ordinary 
coryza. Physical weakness, weariness, and depression of spirits are 
almost invariably present, and they sometimes reach an extraordinary 
degree. Fever is usually moderate (100° to 102°), but may be 104° to 
105° for several days, and then gradually subside. It may terminate 
by crisis (Fig. 77), or may assume an intermittent or remittent type 
(Figs. 78 and 79). In ordinary cases the patient seeks relief first for 
the headache, severe aching pain in back and limbs, and extreme 
weakness ; if these are relieved he is apt to complain most of incessant 
racking cough, often due more to a tracheitis than to bronchitis. 
Nausea and vomiting are not uncommon, especially in the morning, at 
which time also the patient frequently feels worse than he does later 
in the day. Sleep is broken and restless, and may be accompanied by 
drenching perspirations. Severe neuralgic pains are common. 

In some cases the disease attacks the stomach and bowels especially, 
and vomiting with diarrhoea are the prominent symptoms. In others 
the predominant symptoms are nervous, and great pain with prostra- 
tion masks any catarrhal symptoms. Torpor and delirium may be 
present. Sometimes a prolonged and severe attack of asthma marks 
infection in susceptible persons. 

The duration of the disease is from a few days to a few weeks. 
Convalescence is remarkably tedious, and is characterized by persistent 
weakness. Sweats are often annoying during this time. The heart 
often continues for some time to beat too frequently and to be easily 
excited by exertion. Relapses are common. 

Diagnosis. Bacteriological Diagnosis. This is possible when 
the characteristic bacilli are detected by the means described in the 
section on sputum. Influenza in the great majority of cases is easily 
recognized. In certain cases, however, it is to be differentiated from 
pneumonia, typhoid fever, and cerebrospinal meningitis. 

Cases in which the disease sets in with high fever and marked 
chest-symptoms are very apt to be mistaken for pneumonia ; but the 
headache and prostration are more intense, while the respiration is not 
so frequent. Sweats are common, and albumin and casts in the urine 
are by no means rare. Physical exploration shows that both lungs 
are involved, though often not to the same degree. Resonance is im- 
paired, and auscultation shows moist crepitant and subcrepitant rales, 
which seem to be due to an oedematous condition of the lung-tissue, 
associated with a diffuse bronchitis. A true lobar pneumonia is rarely 
present even as a complication. 

If diarrhoea is one of the symptoms, typhoid fever has to be excluded. 



326 GENERAL DIAGNOSIS. 

This is extremely difficult in the first two or three days. As a rule, 
headache, backache, nausea, and sleeplessness are at this time greater 
in influenza, the spleen is not so much, if at all, enlarged, the diarrhoea 
can be checked, and tenderness and pain in the right iliac fossa are absent. 

It can be distinguished from cerebrospinal meningitis by noting the 
fact that it begins with coryza, whereas cerebro-spinal meningitis 
often sets in with chill, vomiting, and faintness ; the headache in the 
former is usually frontal, hi the latter occipital, and accompanied by 
stiffness of the back of the neck. Further, in cerebro-spinal menin- 
gitis there are often swellings of the joints, delirium alternating with 
coma, and in young subjects convulsions are common. 

Finally, it may be said that the pronounced diagnostic feature is the 
preponderance of general symptoms over local inflammations. The 
occurrence of undue exhaustion, extreme general neuralgias and myal- 
gias, high fever, and profuse sweats, without intense catarrh or inflam- 
mation to account for or co-ordinating with them, is of the highest 
diagnostic significance. The presence of an epidemic, the contagious 
nature of the affection, the sudden onset, and the bacteriological diag- 
nosis, all point to influenza. 

Epidemic Cerebro-spinal Meningitis. 

In this infection more than all others the course of the temperature 
is without diagnostic significance unless it be that this want of a char- 
acteristic course is significant. Its extraordinary irregularity is most 
striking when a large number of charts are examined. The fever may 
have the course and exacerbation of a typhoid temperature, but it is 
more similar to that of tuberculosis. It is often of very short dura- 
tion, followed by a prolonged subnormal temperature. It may be high 
from the immediate onset of the disease, or remain below 100° for 
several days, and then suddenly rise to a great height. Remissions 
and exacerbations may attend many of the cases. The most marked 
feature, apart from the irregularity of the temperature, is the inequality 
between the pulse and the temperature. In some instances the pulse 
is rapid, and the temperature is normal or subnormal, while later in 
the disease the pulse may be slow when the temperature rises to a con- 
siderable height. 

Concerning the temperature, then, it may be said that it may be in- 
termittent, remittent, or continuous ; it may be intermittent at one 
period, continuous at another ; it may be afebrile ; it may be afebrile 
at one period and continuous at another. 

Cerebro-spinal meningitis, also known as spotted fever, is an acute, 
specific, infectious, and mildly contagious disease, endemic and epi- 
demic, characterized by evidences of systemic infection, and generally 
also by symptoms depending upon inflammation of the cerebral and 
spinal meninges — particularly intense pain in the back and head, hyper- 
esthesia, retraction of head and neck, delirium, coma, convulsions, and 
vomiting. 

It is most common in cold weather, and in children under fifteen 
years of age. None of the epidemics show a continuous extension. The 



THE DATA OBTAINED BY OBSERVATION. 



327 



period of incubation is unknown, but is probably short. It is free 
from symptoms. The invasion of the disease is abrupt, although in 
some instances the patient may complain of rheumatoid pains in the 
limbs or a joint, and headache and weakness. Usually the first 



Fig. 80. 



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Cerebro-spinal meningitis, showing irregularity of pulse and temperature. (Councilman.) 

symptom is a severe chill, which may awaken the patient from sleep. 
In other cases the initial symptom is a convulsion. Then quickly 
follow repeated vomiting, intense headache, sometimes accompanied 
by backache, retraction of the head, delirium, and extreme prostration. 

The rise in temperature is moderate, and the pulse is as often slow 
as frequent. The face is pale and livid, expressing suffering, and the 
patient may toss from one side of the bed to the other, begging some 
relief for his headache. Simple stiffness of the muscles of the neck 
may prevail. The pain in the head may be occipital or frontal. The 
pain in the back becomes more severe, and root-pains dart in all direc- 
tions, but especially into the limbs or joints, which may be swollen and 
tender to the touch ; in fact, the whole skin is hypersesthetic and the 
reflexes are increased. The spinal muscles become rigid, and the head 
is often retracted. Less frequently the back is arched and trismus 
occurs. Delirium is common at night. It may develop very early or 
appear at a late period of the disease. It is sometimes violent or low 
and muttering. It is often of a sportive type, the patient making 
absurd remarks, cracking jokes, or singing snatches of a comic song. 
Delirium may alternate with tonic or clonic convulsions and with 
stupor. The appetite is poor, the bowels constipated. A remission 
may occur on the third day, with temporary improvement of the 
symptoms. 

As the attack progresses there may be strabismus, Avhich is usually 
divergent, inequality of the pupils, nystagmus, ptosis, and optic neu- 
ritis. Vertigo, tinnitus, anosmia, and photophobia are common. 



328 GENERAL DIAGNOSIS. 

Hyperesthesia and delirium persist. Facial paralysis, a monoplegia, 
a hemiplegia, or a paraplegia may occur. The pulse becomes more 
frequent and the fever continues. In favorable cases improvement 
now begins, the headache and root-pains abating, and delirium and 
spasms becoming less frequent. In unfavorable cases the convulsions 
may become more severe and end in fatal coma, or the patient may 
sink into a typhoid condition, with nephritis as a complication. Coma 
may come on in the beginning and continue until death. 

The skin eruptions, which explain the name " spotted fever," are 
not always present and exhibit no constant character. Herpes and 
petechia are the most frequent ; in other cases the eruption is a pur- 
plish mottling, or is macular, or the eruption resembles that of measles. 
Herpes is most common on the nose and mouth, then on the cheek, 
forehead, eyes, and ears. The blood shows a leucocytosis, the increase 
being due to the polynuclear leucocytes. 

In the malignant (fulminating) form of the disease death occurs in 
a few hours, or two or three days. Such cases are apt to arise early in 
an epidemic. The patient has a violent chill ; delirium occurs early ; 
the headache is less intense, or at any rate gives way rapidly to stupor 
and coma. The pulse is frequent and feeble ; there may be no rise of 
temperature, the skin being cool, clammy, and cyanotic. Local or 
general convulsions may occur. The eruption may be purpuric, and 
ecchymoses may even occur. The urine is scanty and contains albu- 
min and casts. 

Mild cases usually occur late in epidemics. They are characterized 
by severe aching in the head, back, and limbs, nausea, vomiting, 
vertigo, and prostration. They closely resemble the nervous type of 
influenza, and would escape recognition except during an epidemic. 

An abortive form, ending in recovery in two or three days, and an 
intermittent form, with exacerbations on alternate days, have been 
described. 

The duration of the disease is from a few hours to two or three 
months. In ordinary favorable cases there is decided improvement 
toward the end of the first week, and convalescence is established in two 
weeks. It may become chronic and last for weeks, and, as already stated, 
may be fatal in a few hours. Relapses are common in some epidemics. 

The most frequent complications are on the part of the lungs and 
heart, particularly pneumonia and endocarditis or pericarditis. Pneu- 
monia often occurs so early that it is difficult to decide whether it is 
primary with marked nervous symptoms, or is only a complication of 
the cerebro-spinal fever. Nephritis also occurs. 

The most frequent sequels are deafness, blindness, headache, and local 
palsies. 

Diagnosis. The diagnosis in the presence of an epidemic is not diffi- 
cult, although an absolute diagnosis can only be made by lumbar punc- 
ture. The fluid withdrawn is more or less cloudy if the patient has 
meningitis. If it is the epidemic form, microscopical examination of 
stained cover-slips and cultures will expose the diplococcus. In some 
cases fluid cannot be secured, either because the spinal canal is filled 
with membrane or the fluid is retained in the lateral ventricles. 



THE DATA OBTAINED BY OBSERVATION. 



329 



The fluid is turbid in the early part of the disease. In some cases 
a purulent sediment forms in the bottom of the test-tube at once. In 
others, the fluid is simply turbid, and after standing contains consider- 
able fibrin and many cells. The fluid secured at the first puncture may 
be more turbid than that secured later, although the symptoms may be 
more severe than at first. If the acute symptoms subside the fluid may 
be clear, and no cells may be found. In the intermittent cases the 
fluid may be clear during the interval that the patient is without 
symptoms. In chronic cases there may be no turbidity. 

The cells in the spinal fluid are chiefly polymorphonuclear leuco- 
cytes — •" pus corpuscles. " Small lymphoid cells and large endothelial 
cells may be present. The latter are phagocytic, and have large oval 
or round nuclei. They may contain leucocytes and blood-corpuscles. 
In the pus corpuscles or leucocytes the diplococci are found • they are 
rarely found outside of the cells. Late in the disease the pus corpus- 
cles do not stain sharply and are degenerated. In chronic cases the 
fluid contains a few pus corpuscles which are smaller than usual, and 
like lymphoid cells. 

Bacteriological Diagnosis. This disease is due to the diplococeus 
intracellular is. This micrococcus appears in diplococeus form as two 
hemispheres the size of the ordinary micrococcus. It stains with the 
ordinary stains for bacteria. It is decolorized by the Gram method. 
The staining is sometimes irregular, some being brightly stained, others 
faintly. There is some variation in the size of the organisms. Both 
variation in size and staining are apparently due to degeneration. The 
two organisms are sharply separated usually, though sometimes they 
seem to be united. (Figs. 81 and 82.) 



Fig. 81. 



Fig. 








Fig. 81. Pas cells containing diplococci from the meninges. A few diplococci are in the exudate 
outside of the pus cells. Between the pus cells there are delicate fibrillse of fibrin. The drawing 
is an accurate representation of a group of cells in the field of the microscope. (Councilman.) 

Fig. 82. Pus cells from an alveolus of the lung in a case of diplococeus pneumonia. The cells 
are swollen and contain immense numbers of diplococci. Both figures from stained cover-slips. 



The organisms do not grow profusely. The blood-serum mixture 
of Loftier as prepared by Mallory is the best medium. It is often 
difficult to make cultures unless a large quantity of material is used. 



330 GENERAL DIAGNOSIS. 

Transfers must be made daily to keep cultures going. The growth 
on the serum mixture forms round, white, shiny viscid-like colonies 
with smooth outlines. They do not liquefy the blood-serum. In 
the tissues the diplococcus is found in the interior of the polynuclear 
leucocytes. 

Cultures. Cultures should be made at the time of puncture. In the 
majority of cases a growth of the diplococcus is found, although even 
in acute cases rarely they may not grow. In chronic cases a growth 
is only rarely obtained. (Plate VIII.) 

This form of meningitis must be excluded from pneumococcus men- 
ingitis, tuberculous meningitis, and streptococcus meningitis. In the 
pneumococcus form the symptoms are comparatively slight and are 
usually preceded by pneumonia. In the streptococcus form the clini- 
cal history is like that of ordinary forms of meningitis. The evidence 
of an infection elsewhere is usually present. Tuberculous meningitis is 
recognized by the methods employed to detect tuberculosis elsewhere 
in a patient suffering from the usual symptoms of cerebro-spinal men- 
ingitis. The most positive method of distinction of the various forms 
is by lumbar puncture. (See Chapter XXI.) 

Kernig's Sign (Kernig, 1884; better, 1898). This sign is of 
value in the diagnosis of meningitis, but is present in any form. It is 
determined by placing the patient in the dorsal decubitus, with the legs 
relaxed and fully extended at the knees. When the child is raised in 
a sitting posture the knees are flexed, and cannot be extended on 
account of contracture of the posterior muscles of the thigh. In adults, 
if the patient is propped up, or seated on the side of the bed, and an 
attempt made to extend the leg on the thigh, there is contraction of the 
flexures. The test can be equally well performed by flexing the thigh 
on the abdomen until it makes a right angle. When an attempt is 
made to extend the leg it will be found that the limb cannot be fully 
stretched out if meningitis is present. 

Diphtheria. 

In this infection the temperature-range is variable. The infection 
may be intense, and yet the temperature remain subnormal, especially 
if the fever is due to the toxin, and not, as is frequently the case, to a 
mixed infection. 

Diphtheria is an acute, specific, infectious, and contagious disease, 
sporadic and epidemic, occurring especially in children from one to six 
years of age, and characterized by insidious or abrupt onset, with mod- 
erate fever, and the development upon the fauces or upon any abraded 
surface of a grayish-white false membrane, which has a tendency to 
extend, especially to the larynx. The subsequent phenomena are 
those of stenosis of the larynx, or toxaemia, with or without superadded 
uraemia or marked cardiac Aveakness ; it is further characterized by the 
liability to paralysis as a sequel. 

Diphtheria is spread by inhaling the expired breath of a diphtheritic 
patient, or breathing air which has been contaminated by the clothing 
of the patient or the discharges from his nose and throat. It may also 



PLATE VIII 



Fig. 1. 



Fig. 2. 



Cerebro-Spinal Meningitis. (Councilman. 



Fig. 



Forty-eight-hour culture of diplococcus intracellularis on Loefner's blood-serum mixture. 



Fig. 2. Abundant growth in twenty-four-hour culture on fresh blood-serum. The colonies are 
minute, very numerous, and somewhat resemble similar cultures of the pneumococcus. 



THE DATA OBTAINED BY OBSERVATION. 



331 



be transmitted directly, as when a fragment of membrane is ejected by 
coughing and infects the mouth or eye of physician or attendant. 
Moreover, it is contained in the sewers of large cities where the dis- 
ease is endemic, and it persists in damp cellars if they have once been 
infected. Hence sewer-gas and cellar-air may carry the disease. 
There is reason also for believing that a similar disease affects birds, 
fowls, and cats at times, and from them may be transmitted to man. 
These facts must be borne in mind in making the diagnosis. 

The specific poison is the Klebs-Loffler bacillus and its toxin. 

While children from one to six years of age are especially liable to 
it, no age is exempt — neither the newborn babe nor the very aged. 

One attack does not protect a person completely against a subse- 
quent attack. 

The period of incubation varies from a few days to two weeks, or 
perhaps longer in exceptional cases. As a rule, it is less than a week. 
It is shorter when the poison is virulent, and when infection has been 
upon abraded surfaces. 

The onset in mild cases is deceptively free from positive symptoms. 
The child is languid, perhaps slightly chilly, and has a little fever, 
with thirst, impaired appetite, and discomfort in swallowing. Unless 
the nature of the trouble is suspected the child is not thought ill enough 
to be kept in-doors. The throat is slightly inflamed, especially about 
the tonsils. The child may protest that there is no pain on swallow- 
ing. In from twelve to twenty-four hours from the onset, sometimes 
later, a grayish pellicle will be found upon the tonsils, and the cervical 
glands will be swollen. 



Fig. 83. 



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Diphtheria. 



In more severe cases the disease begins with chill or chilliness, fol- 
lowed by a rise in the temperature to 102° or 104°, sore-throat, and 
sometimes vomiting, though this is not so common as in scarlatina. 



332 GENERAL DIAGNOSIS. 

Convulsions and delirium may occur if the fever be high or the case 
malignant, but they are not common. Disgust for food makes it diffi- 
cult to nourish the patient. Headache, thirst, and aching in the back 
and limbs may be complained of. Prostration is often very pronounced 
from the first. 

Objective Symptoms. The characteristic false membrane appears 
first as a grayish pellicle upon one or both tonsils, and spreads thence 
to the soft palate and pharynx. The membrane soon becomes thicker 
and whitish in color ; when fully developed it appears like white or 
grayish-white parchment, not lying loosely upon the surface, but em- 
bedded in the mucous membrane, the inflamed swollen edges of which 
rise above the false membrane, surrounding it " as the crystal of a watch 
is surrounded by the rim " (J. Lewis Smith 1 ). As the membrane becomes 
older it may be brownish, or even blackish in color, if tincture of iron 
has been given. If it is forcibly torn from the underlying surface hem- 
orrhage is excited and the membrane is reformed. As the membrane 
loosens spontaneously there is often marked inflammatory reaction at 
the edges of the surrounding mucous membrane, and in the tonsils 
there may be decided sloughing, with a dark, gangrenous appearance. 

The temperature usually falls on the second or third day, but this 
does not indicate either a favorable or an unfavorable end. A temper- 
ature but little above normal is not uncommon in profound toxaemia. 

Albumin is usually present early, and often tube-casts and renal epi- 
thelium also can be found. The submaxillary and cervical glands are 
swollen, and it may be difficult to open the mouth sufficiently to inspect 
the throat. 

As pointed out by Buzzard and McDonnell, the patellar tendon 
reflexes are often abolished as early as the first day. 

In favorable cases the membrane ceases to extend after three or four 
days ; there is no extension to the larynx ; the urine is free from albu- 
min, or only slightly albuminous ; and the pulse is not more than 100 
to 120 and of good force. 

In unfavorable cases the membrane shows a tendency to extend, 
either upward into the nasal fossae, producing a thin, irritating, excori- 
ating discharge from the nostrils, and rendering mouth-breathing neces- 
sary ; or it may extend also to the ears through the Eustachian tube, 
or into the maxillary sinus ; or the extension may be downward into 
the larynx, producing laryngeal stenosis. This is announced by hoarse- 
ness, with rapidly increasing difficulty in breathing. Inspiration is 
high-pitched, noisy, and difficult ; the patient brings all the accessory 
muscles of respiration into play, the alae of the nose play, the ribs are 
sucked in, and still he pants for breath. Every now and then a parox- 
ysm of coughing produces cyanosis. 

In other unfavorable cases the throat-symptoms are not dangerous, 
but uraemia develops. The urine is scanty, contains a large amount 
of albumin, considerable blood, and numerous blood, epithelial, and 
granular casts. There are oedema of the feet and puffiness of the eye- 
lids. There is apt to be repeated vomiting ; convulsions, followed by 

1 KeatingVOvclopsedia of Diseases of Children, 1889, vol. i. 606. 



THE DATA OBTAINED BY OBSERVATION. 333 

coma, and death may end the scene, or the patient may slowly emerge 
from the dark valley. 

In still other cases the diphtheritic poison affects the heart. The 
pulse becomes feeble and very frequent, the first sound very faint ; 
acute dilatation of the right heart may occur. There may be faintness 
and a tendency to cyanosis on the slightest provocation, or attacks of 
sinking and faintness may come without warning ; in still other cases 
sudden exertion induces paralysis of the heart, and death. 

In some malignant cases the patient is overwhelmed by a large dose 
of the poison, and dies in from one to three days in collapse from acute 
toxsemia, without any special local symptoms to account for it. In 
others the false membrane extends rapidly over the fauces, pharynx, 
and nasal cavities to the larynx ; death occurs from early obstruction, 
or, if it is postponed, there is extensive sloughing, with death from sec- 
ondary blood-poisoning or septic pneumonia. 

In exceptional cases the membrane is primary in the nares or larynx, 
or develops upon some abraded surface, as a burn, or in the vagina of 
a puerperal woman. It may also attack the mucous membrane of the 
eye or the seat of a recent operation. Diphtheria also occurs as a com- 
plication of other diseases, particularly scarlet fever. 

The most frequent sequelse are anaemia, albuminuria, and paralysis. 
The latter comes on in from one to two weeks after convalescence has 
set in, but it may appear much earlier, and in exceptional cases later. 
It may be marked simply by loss of the knee-jerk, which has been 
alluded to already in the symptomatology, or involve the palatal and 
pharyngeal muscles, causing nasal voice, difficulty in SAvallowing, and 
regurgitation of food through the nose, or there may be multiple 
peripheral neuritis. 

Loffler's or the Klebs-Lbffler Bacillus. This is found in diph- 
theritic pseudomembranes, especially in the deeper portions. It is not 
found in the blood. 

Morphology. A bacillus 2 to 3/* long by 0.5 to 0.8/z broad, 
straight or slightly curved, with very many irregular forms. (See Fig. 
84.) 

The pseudo-diphtheritic bacillus resembles the genuine in all respects, 
except that it is not pathogenic. It seems to be an attenuated form of 
the former. 

Biological Properties. It is facultative anaerobic, non-motile, 
and does not liquefy gelatin. It multiplies by fission. Stains with 
Loffler's blue. Certain points are stained intensely, almost black. It 
grows in nutrient gelatin, nutrient agar, or bouillon, but best of all in 
Loffler's blood-serum mixture (see page 243) at 35°. (Death-point, 
58°, ten minutes' exposure.) It forms large, round, elevated colonies, 
grayish-white in color and moist. There is no visible growth on 
potato. Milk is a good soil. (See Plate VII., Fig. 4.) 

On inoculation it causes a diphtheritic pseudomembranous inflam- 
mation. It generates a very poisonous toxin. 

Diagnosis. Diphtheria is distinguished from ordinary pharyngitis 
by the presence of membrane. From follicular tonsillitis by the pro- 
jecting mouths of the follicles containing a creamy-white exudate. Later 



334 



GENERAL DIAGNOSIS. 



the exudate may cover the entire surface of each tonsil and be difficult 
to distinguish from false membrane. The points of distinction are 
that in the former the exudate lies upon the surface and can be brushed 



Fig. 84. 




Colonies of pseudo-diphtheria bacilli 



c. Colonies of diphtheria bacilli, X 249. 




'*¥ *II 



'•It ^S 



T 






d. Diphtheria bacilli, X 1000. 

off without force and without leaving a bleeding surface ; whereas in 
diphtheria the membrane is embedded in the mucous membrane and 
cannot be torn from it without force. A raised, red inflammatory 
border of mucous membrane at the junction of the patch is strongly 
suggestive of diphtheria. In tonsillitis there is no appearance of mem- 
brane upon the soft palate or pharynx. Furthermore, in tonsillitis the 
onset is attended with more fever and pain in swallowing than is true 
in simple tonsillar diphtheria. The existence of albuminuria and swell- 
ing of the cervical glands indicates diphtheria, and the absence of knee- 
jerk is an important but not constant diagnostic sign of diphtheria. 
The presence of the Klebs-Loffler bacilli in a culture from a suspected 
throat is proof of the existence of diphtheria. 

Septico-pysemia. 

The clinical course of this infection and the bacterial causes have 
been considered in Chapter XVI. (Class III. of infections). It will 
be recalled that the phenomena may attend a number of the infections 
described in this and in previous chapters. When occurring in the 



THE DATA OBTAINED BY OBSERVATION. 335 

course of pneumonia, diphtheria, typhoid fever, etc., its causal origin is 
recognized by the methods discussed in the chapter referring to these 
infections. Septico-pysemia caused by pyogenic organisms, the so-called 
" cryptogenetic sepsis/' is recognized by bacteriological examination of 
the blood ; by an examination of the morbid secretions, or by an exam- 
ination of the products of inflammation. Bacteriological examination 
of the blood has its limitations. Usually only late in the course of the 
disease and in the more intense infections can the bacteria be found. 
Examination of the pus from foci of suppuration in the bones (osteo- 
myelitis), in the joints (pyaemia), in the serous cavities (empyema, 
pericarditis, peritonitis), in the lungs (see Sputum), in the genito-urinary 
tract (see Urine), will show the infective micro-organism. 

The causal micro-organism is detected by cover-slip preparations 
and cultures. (See Chapter XXI.) 

Glanders. 

A general febrile disturbance which attends this infection is similar 
to that of the infective granulomata (Class IV. of infections). In severe 
cases the symptoms are like those of an acute septicaemia. It is an 
infectious, constitutional disease, transmitted from horses to man, 
appearing in an acute and chronic form, and characterized by an erup- 
tion, ozaena, small tumors, ulcerations, cough, and death in coma or 
collapse in from one to four weeks in the acute form, or in three or 
four months in the chronic form, the symptoms in the latter resembling 
at times syphilis and at times tuberculosis. 

The disease is rare in man. It may be acquired by direct inocula- 
tion of an open wound with the pus from a glanderous ulcer or nasal 
mucous membrane, or indirectly from infected straw or other material. 
The raw meat of a glandered animal also has infective power. 

In acute glanders the onset is marked by headache, slight fever, and 
pains in the limbs. If a wound has been infected this becomes pain- 
ful, swollen, and behaves like any poisoned wound. Sometimes a 
diffuse redness, resembling erysipelas, spreads from the infected point. 
Fagge refers to a case in which the first complaint was of pain in the 
side and dyspnoea, so that acute pleuropneumonia was suspected. 

An eruption, consisting first of papules, which rapidly become flat 
vesicles and then pustules or bullae, appears in the first day or two, or 
sometimes not for a week or even longer (Fagge). The bullae or pus- 
tules rupture and give vent to a thin purulent discharge. 

There may be hard, painful lumps in the muscles, with subsequent 
suppuration (farcy). 

Ozsena is not always present. It appears in the second or third 
week of the disease. It consists of a mucopurulent, then purulent, 
foetid discharge from the nose. The latter subsequently swells and 
becomes red and very painful. Ulcers and even necrosis of the sep- 
tum are the lesions ; the same catarrhal condition may exist in the 
throat, eye, larynx, and mouth, accompanied at times by ulcers and 
false membrane. The patient gradually sinks into a septicaemic condi- 
tion, with irregular fever, dry brown tongue, albuminuria, delirium, 
coma, and collapse. 



336 GENERAL DIAGNOSIS. 

The duration of the acute form is from one to four weeks. Only 
one in thirty-eight eases collected by Bollinger ended in recovery. 

In the chronic form there are ulcers upon the hand, face, forehead, 
or elsewhere. In other cases the lesions are abscesses in connection 
with joints which are followed by persistent fistula?. In still other 
cases there is pustular eruption. Ozsena may or may not exist. In 
still other cases the prominent symptoms are cough, bloody expectora- 
tion, hoarseness, fever, and emaciation. Bollinger reports seventeen 
recoveries in a total of thirty-four cases of chronic glanders. 

Diagnosis. Acute glanders is distinguished from rheumatism by 
the history of the case, the occupation of the patient, the existence of 
an open, irritable sore, and the fact that while the joints may be 
painful, they are rarely red and swollen, as in rheumatism. Subse- 
quently the appearance of pustules, bulla?, and ozsena makes the case 
clear. 

The same peculiar features serve to distinguish it from pyaemia, 
malignant pustule, and other infectious diseases. 

In a suspected case of chronic glanders a correct diagnosis might be 
arrived at by inoculating a mule or a horse with the nasal mucus or 
pus from a farcy. 

Bacteriological Diagnosis. The specific germ is the bacillus 
mallei. This is a short, non-motile micro-organism resembling the 
tubercle bacillus. It is 2 to 3/^ long, and 0.3 to OAju broad, frequently 
having spores on the ends. It stains readily with all the basic aniline 
dyes, although taking up the dyes irregularly. 

The diagnosis is readily made by the method of Strauss. A portion 
of the suspected tissue or a culture from the lesions is inoculated into 
the peritoneal cavity of a male guinea-pig. If the case is one of glan- 
ders the testicles begin to swell in about thirty hours, and an orchitis 
with abscess develops. The diagnostic sign is the tumefaction of the 
testicles. 

The Mattein Test Mallein is the filtered products of the growth of 
the bacillus on fluid media. It is allied to tuberculin. The injection 
of it in a suspected case produces a reaction similar in its course to 
the tuberculin reaction if the case is one of glanders. 

Cholera. 

An acute, specific, infectious disease, endemic in parts of India, but 
occurring in epidemics elsewhere, characterized by the outpouring into 
the stomach and bowels of large quantities of a serous fluid resembling 
rice-water, which fluid is usually vomited and discharged from the in- 
testines. It is further characterized by an algid state of collapse and 
by painful muscular cramps. 

The specific poison of cholera is believed to be the comma-bacillus 
of Koch and its ptomaine. 

The native habitat of cholera is India, particularly the neighborhood 
of Calcutta ; here it is endemic, and thence it is liable to spread in suc- 
cessive epidemic waves along the lines of travel by sea and land, over 
the whole world. It is scarcely, if at all, contagious ; the poison is 



THE DATA OBTAINED BY OBSERVATION. 337 

contained in the vomit and dejections, which contaminate the drinking- 
water, food, and clothing. The cholera-bacillus preserves its vitality 
for long periods of time in water, especially if the water is slightly 
alkaline and contains vegetable matter, and in moist clothing, as rags. 

The period of incubation is probably short in the majority of cases, 
lasting only a feAV days. Occasionally it is two weeks. There are 
usually no definite symptoms during this time, but there may be a 
sense of weakness, with loss of appetite and dyspeptic symptoms. 

Fiest Stage. The first stage, that of premonitory diarrhoea, is 
better regarded as the beginning of true cholera. It is characterized 
by profuse watery stools of a yellow or light-yellow color, and alkaline 
in reaction. They are accompanied by a rumbling noise in the bowels, 
but are passed without pain. From six to a dozen of these passages 
occur in twenty-four hours. The patient feels faint and exhausted 
after them, and may suffer with nausea, but vomiting is not usual. 
In severe cases there may be cramps in the calves of the legs. The 
voice is faint and husky, thirst intense, the tongue white and moist. 
The temperature is normal or slightly depressed. 

This stage may last from two days to a week, depending upon treat- 
ment. In some cases it is wholly absent, and the patient is ushered 
abruptly into the second stage. 

Secoxd Stage. This usually comes on during the night. The 
patient is seized with vomiting, which is at first bilious, but the fluids 
rapidly lose all color and become like rice-water. The stools likewise 
resemble water in Avhich meal has been stirred, or in which rice has 
been soaked — a semi-transparent fluid, with particles of epithelium 
resembling rice floating in it. This fluid seems to well up and re- 
gurgitate rather than to be vomited from the stomach, and to gush in 
quantities of a quart or two from the anus. Sometimes vomiting and 
diarrhoea occur at once. The patient has unquenchable thirst, and is 
tortured with painful cramps of the toes, legs, belly, and diaphragm. As 
the discharges continue the patient becomes more and more exhausted ; 
the nose is pinched and twisted, the eyes sunken, the lips bluish, and 
the whole body may shrink beyond recognizable proportions. 

The skin is cold and moist, the breath icy, and the temperature 
under the tongue is sometimes as low as 78° to 80° F. In the vagina 
and rectum it may be normal or slightly above normal. The patient, 
however, often has a sensation of heat. The urine is very scanty, con- 
taining albumin and sugar, or it may be suppressed. The pulse is 
very small and feeble, 100 to 120. The mind is clear, but the patient 
is listless, answering questions in an extremely faint voice and with 
manifest effort. 

Third Stage. From this collapsed and algid condition the patient 
may slowly emerge, the skin becoming less cold, the cramps less severe. 

A return of the secretion of urine is a hopeful sign. The reaction, 
however, may simply introduce a low typhoid condition, with fever, 
dry brown tongue, subsultus, low muttering delirium, and coma. 

In some cases serum is poured out into the stomach and intestines 
and is retained there. The patient may be seized while walking with 
dizziness, faintness, extreme prostration, and early collapse. 

22 



338 GENERAL DIAGNOSIS. 

In other cases the patient is smitten down with profuse vomiting 
and purging, dying algid and collapsed in a few hours, no reaction 
appearing. 

In favorable cases the vomiting ceases, the stools , become less fre- 
quent, and are tinged with bile and have a faecal odor. The urine 
increases in volume, while the albumin diminishes. Convalescence is 
very protracted. Anaemia, great debility, feeble digestion, and some- 
times obstinate diarrhoea delay complete recovery. Relapses are fre- 
quent. 

In other cases reaction brings improvement in the gastro-intestinal 
symptoms, but uraemia develops, death following in convulsions or 
coma. 

The most frequent complications and sequelce are eruptions, chiefly 
erythematous, ulcerations and bed-sores, parotitis, and a painful tetanic 
spasm of the flexor muscles of the hands, forearms, legs, and feet, occur- 
ring between the tenth and fifteenth days of convalescence (Stills). 

Diagnosis. The chief points in the diagnosis from other affections 
are the knowledge of exposure to cholera ; the character of the vomit 
and dejecta, which contain the comma-bacillus (for its detection see 
under Bacteriology) ; the cyanosis ; the rapid development of collapse, 
with cold skiu, icy breath, torturing cramps, and greatly shrunken 
visage and body. 

Cholera morbus differs in that the stools remain turbid with bile or 
faecal matter, or contain blood ; they never present the rice-water 
appearance. Moreover, the passages are frequently preceded by col- 
icky pains. Cyanosis and collapse are extremely rare. The stools 
do not contain the cholera-bacillus. 

Other forms of acute toxic g astro-enteritis, whether from ptomaine- 
poisoning or from corrosive poison, are to be distinguished by the 
history, the difference in the character of the stools, and the compara- 
tive absence of painful cramps in the legs, of cyanosis, and of collapse. 

Bacteriological Diagnosis. Koch remarks : l " As cholera resem- 
bles in clinical symptoms cholera nostras, infantile cholera, certain 
forms of peritonitis, certain organic poisons, and poisoning by arsenic, 
it is important to attain some means of making a definite diagnosis." 

Spirillum Choler^e Asiatics. The Comma-bacillus. The 
comma-bacillus of Koch is the specific causative agent of cholera. In 
a disease so wide-spread in times of epidemics, and so fatal, it is of 
great importance to be able to recognize the bacterium that produces 
it. Works on bacteriology give a fuller study than is permitted here, 
and should be consulted. This is more especially true because, while 
the bacilli, as found in the stools, can be stained quite easily, and may 
be recognized by expert microscopists, in the great majority of cases 
their recognition is only effected by bacteriological examination. They 
have no specific relation to dyes, as have tubercle bacilli. 

Microscopical Examination. The cholera bacillus is a short, 
more or less bent rod, both shorter and thicker than the tubercle 
bacillus, and generally shaped like a comma. They are often found 

1 Zeitschrift fur Hygiene und Infektionskranheiten, 1893, vol. xiv., No. 2. 



THE DATA OBTAINED BY OBSERVATION. 339 

placed end to end, and thus form a curve like a spiral. They are 
always present in the stools of cholera patients and sometimes in the 
vomit. They are particularly abundant in the mucous floccules of the 
rice-water discharges, and can be obtained from the linen soiled by 
the same. Cover-slip preparations are made from these portions by 
placing a uniform film on the slip, drying it in the air, and then pass- 
ing it through the flame of a Bunsen burner or spirit-lamp. 

The spirillum, or so-called " comina-bacillus," consists of a slightly 
curved rod, with rounded ends, 0.8 to 2ii long by 0.3 to 0.4/i broach 
It is usually slightly curved like a 
comma, but may form a half -circle, or FlG - 85 - 



two may be joined like an S. Under j k « 

certain circumstances they grow out ! // III 

into long spiral threads. By Lo filer's , 1 \fi h ' ct m'\ ,L l , [ 



method a single flagellum is found on 

the rods. It stains with anilines, but 

slowly. An aqueous solution of fu 

sin (Zeihrs red) is the best. (See 

Plate III., Fig. 3, a; and Fig.^ 85). f \i£\l\ N v ,„ 61 - 

In addition to the cholera-bacilli, the (7 •#, &$t y I > s h ! " ,] y 






bacillus coli communis and other in- I'j'c J"/ ^?.^ , ,-> -'•^ # i§V- I ' 

testinal bacteria are found. The \ ' *'\% { i [ \ ( J "t/^ * i \ 

cholera-bacilli lie in groups in the j U 1 ^ v »' / J \ fJ '/.i ) \ 

thread-like strands of mucus. They i '-(''J %) '*' fop/l I 'X 4 

form in heaps, the bacilli lying in the \' »• J I / \ x fl\\\ 
same direction. Koch holds that this ; y '* j /// 

mode of grouping is characteristic ' 

and diagnostic. He further holds cholera spirilla & oym on moist linen - 

^i L •£• i -it t • l X 600. (After Koch.) Cultivated from the 

that if bacilli coll are 111 close prox- dejections after two days. 

imity to numerous scattered bacteria 

resembling the cholera bacilli the case is one of Asiatic cholera. 

The bacillus of cholera nostras and one found in cheese by Deneke 
resemble the comma-bacillus in shape, though somewhat larger, but 
they have bacteriological peculiarities by which they can be differ- 
entiated. 

Biological Properties. Aerobic (fac. anaerobic), motile, liquefying. 

Cultures. Growth. Grows in ordinary media at room tempera- 
ture ; faster in oven. Does not grow except between 14° to 42° C. 
Gelatin plates : At the end of twenty-four hours small white colonies 
appear deep in the gelatin. These grow toward the surface and liquefy 
the gelatin in a funnel-form, which gradually deepens, and at the 
bottom of the colony is seen as a small white mass. Under low power 
the colony is white or pale yellow, margins uneven, texture granular, 
surface looks as if covered with bits of glass. "\Yhen liquefaction 
begins a dim halo forms about the colony, which by transmitted light 
is roseate in hue. 

Stab-culture in Xutrient Gelatin. Develops all along the puncture, 
liquefaction beginning near the surface, forming a funnel which en- 
larges, and finally the gelatin almost entirely liquefies. (See Fig. 87.) 
On potato a thin, transparent grayish-brown layer. Milk, bouillon, 



340 



GENERAL DIAGNOSIS. 



blood-serum, are all favorable. In media with other bacteria it soon 
dies. Death-point, 52° 5'. In moisture it retains vitality for months, 
but is killed by drying. 




Fig. 87. 




Cholera spirilla. Tube-cultivations. 

(Flugge.) 
a, after two days ; b, after tour days. 



Fmkler and Prior's comma-bacillus. 

Cultivation in gelatin. 

c, two days ; d, four days old. 



Peptone-cultivation. A small quantity of the dejection of some 
flake of mucus is inserted with a platinum loop into a sterilized 1 per 
<?ent. peptone solution. The solution is maintained at 37° C. The 
cholera bacteria are aerobic, and develop on the surface of the peptone, 
while the faecal bacteria remain in the deeper layers. As soon as the 
peptone is cloudy a drop from the surface is examined microscopically. 
Within six hours the surface is overwhelmed with a pure culture of 
cholera bacilli. Later they are mixed with bacteria coli. The exami- 
nation should be made from six to twelve hours after the peptone solu- 
tion is inoculated. The peptone solution should be strongly alkaline, 
and a 1 per cent, solution of common salt should be added. Care must 
be taken to see that the solution contains sufficient soda. In plate 
cultivations the cholera-bacilli are overwhelmed by the fecal bacteria. 

Agar-plate Cultivation. The growth is not so characteristic as 
it is in gelatin. The cholera- bacilli form large colonies of light gray- 
brown transparent appearance. Colonies of other bacteria are less 
transparent. The colonies can be obtained in from eight to ten hours 
after exposure to a temperature of 37° C. Microscopical examination 
of the colonies must be made. 

Cholera-red Reaction. Cholera-cultivations contain indol and 
nitrous acid, and produce a red purplish color if sulphuric acid is added. 
This color is produced by other bacteria also, but by none other of the 
bacteria that are curved. Care must be taken to make the cultiva- 
tions with suitable peptone and to have the sulphuric acid free from 
nitrous acid. 



THE DATA OBTAINED BY OBSERVATION. 341 

To determine its presence in the shortest time, inoculate diluted 
bouillon. After ten to twelve hours a wrinkled film has formed. 
Make another culture in the same way from this, then inoculate gel- 
atin plates and use color-test on these. 

Ixoculation. The agar-cultivations are employed. They must be 
introduced into the abdominal cavity of the guinea-pig. The injection 
must not be made into the intestine, a matter which requires considera- 
ble practice. Xo other spirillum or curved bacillus produces the symp- 
toms of cholera. 

Acute Dysentery. 

The fever which attends this infection is, from a clinical stand-point* 
the least characteristic symptom. It varies in part with the age of the 
patient. In the aged it is subnormal, normal, or moderate. In the 
young it is usually very high. It differs with the character of the 
infection. If a mixed infection prevails the temperature is not unusual. 

The term dysentery is applied to an inflammation of the intestinal 
tract, chiefly the colon, which is attended by the symptoms of intesti- 
nal catarrh in intense degree, with mucus and bloody discharges and 
the general symptoms of fever and prostration, followed by extreme 
exhaustion, and at times the occurrence of abscesses in the portal cir- 
culation, or of paralysis, arthritis, nephritis, or profound anaemia. It 
was formerly thought to be an epidemic, mildly contagious disease. 
Although of frequent occurrence sporadically, it is especially common 
in jails and institutions, in camps, or where people are crowded together, 
when at the same time hygienic conditions are most unfavorable. It 
usually occurs in the summer or fall, and is attributed to the drinking 
of impure water. A form most common in the tropics is called tropi- 
cal dysentery. Recent investigations have shown that catarrhal dysen- 
tery due to the above-mentioned circumstances may occur, and that 
in addition " tropical " dysentery, which is not confined to the tropics, 
is associated with inflammation and ulceration of the bowel, attended 
by the amoeba dysenteric or A. coli. 

Catarrhal Dysentery may be limited to simple inflammation of the 
intestine, or may be followed by ulceration. Its first symptoms are 
those of intestinal catarrh. There is indigestion, with loss of appetite, 
perhaps vomiting, and slight diarrhoea. These symptoms may be the 
immediate effect of the diarrhoea. At the end of three or four days a 
chill may take place, showing the setting hi of an infection. The diar- 
rhoea is attended by pain, at first seated around the umbilicus ; it then 
becomes marked in the course of the colon. The movements are fre- 
quent, preceded by constant desire, and attended by extreme tenesmus. 
The stools, which were first faecal and fluid, soon become scanty, and 
consist almost entirely of mucus and blood. The symptoms of local 
proctitis are severe ; there is a sensation of a hot mass in the rectum. 
There may be strangury, and prolapse of the anus may ensue. 

With the continuance of acute pain and frequent evacuations the 
skin becomes hot and dry ; thirst, nausea, and occasionally vomiting 
occur. The temperature continues at about 103° ; the pulse is rapid. 
The patient is weak and restless ; the tongue is red and raw. 



342 GENERAL DIAGNOSIS. 

If the disease is severe from the start, or the course is unfavorable, the 
stools may contain pure blood, or they may be dark in color, and con- 
tain shreds of membrane. Pain and tenesmus disappear, and the evac- 
uations become constant or involuntary. Restlessness is aggravated ; the 
extremities become cold ; mild delirium sets in. The tossing and rest- 
lessness are quite characteristic, and are attended by sighing and some 
dyspnoea. The pulse is rapid and feeble ; the heart-sounds are weak- 
ened ; the tongue becomes dry and brown, the mouth is parched, and 
thirst is intense ; ulcers develop in the mouth and sordes collect around 
the teeth. The delirium increases to stupor, and from that to coma. 
The urine, at first high-colored and scanty, becomes bloody, and con- 
tains albumin and casts. Although the fever continues during this 
stage, the extremities become cool, perspiration breaks out over the 
forehead, and, instead of typhoid symptoms, the symptoms of collapse 
may ensue. If the disease is prolonged and the bowels are controlled, 
the symptoms of pyaemia may develop. 

The anaemia that ensues is extreme, and there is great wasting. 
Convalescence is slow and may be attended by chronic diarrhoea. 
Before it is established ulcers of the skin may form on various parts 
of the surface of the body. Arthritis is of common occurrence, and 
paralysis may occur during convalescence on account of peripheral 
neuritis. Chronic dysentery may succeed the acute. It is thus seen 
that the attacks may be of moderate severity or extremely grave ; 
during the course of the latter gangrene of the lower bowel may take 
place. 

Amoebic Dysentery ; Tropical Dysentery. This differs from 
catarrhal forms of dysentery in many respects. The onset may be 
abrupt or gradual, as in the previous form, with symptoms of intestinal 
catarrh. In most of the cases a frequent and painless diarrhoea follows 
a period of slight ill health. The diarrhoea alternates with short 
periods of constipation ; the stools are watery and contain mucus, but 
no blood. The course of the disease is irregular. There may be inter- 
missions and exacerbations of the diarrhoea without obvious cause. It 
may rapidly pass from one grade to another, or become chronic. One 
form is the gangrenous, which may scarcely be appreciated by the 
symptoms until the autopsy shows it to have been present. True 
relapses are common, and the tendency to chronicity is very great. 
The milder cases are attended by weakness, emaciation, and pallor ; 
the expression is dull ; the skin is dry and sallow ; the tongue pale, 
flabby, and moist, slightly furred ; the abdomen is normal or retracted ; 
the temperature does not rise above 100°, and the pulse ranges from 
70 to 90. Sleep is disturbed by frequent evacuations of the bowels. 
In the grave form the face is drawn, or cyanosed or flushed, the ex- 
pression anxious ; the mind is clear. Anorexia, intense thirst, and 
sleeplessness are present. The abdomen is greatly retracted, and there 
may be free sweating. The temperature is normal or subnormal, the 
pulse small and rapid. Progressive anaemia and loss of flesh are 
prominent and dominate the intestinal symptoms. The skin is dry 
and harsh, and of a dull greenish-yellow color if the cases are pro- 
tracted. 



THE DATA OBTAINED BY OBSERVATION. 343 

The special features of amoebic dysentery are : 1. The anosmia- 
This is due to diminution of the red cells and the haemoglobin, first, 
because of the action of the amoebae upon the red blood-corpuscles, 
which they destroy ; second, the direct loss of blood ; and, third, mal- 
nutrition. The first is the most prominent. 

2. Diarrhoea may be the only feature of the disease. It is charac- 
terized by great variation in character and frequency in all grades and 
during different periods of the disease. Intermissions and exacerba- 
tions may be observed at any time. The latter begin suddenly, and 
subside in the same manner. They last from two to ten days. The 
intermissions continue from one day to three weeks, during which the 
faeces are soft, but contain mucus. Councilman and Lafleur have ob- 
served this periodicity to be most marked in cases complicated with 
hepatic abscess. 

3. The Stools. The stools are extremely variable according to the 
severity of the ulceration, and also vary in number and character from 
day to day in individual cases. In the gangrenous form they number 
thirty or forty in twenty-four hours at first, then decline, so that 
toward the end of fatal cases but three or four take place. At first 
the movements are small, and consist of mucus with more or less 
bright blood and small faecal masses. As ulceration advances the stools 
change, they become more copious and watery, faeces are absent, blood 
is not so frequent. Shreddy masses of grayish or yellow color, mixed 
with mucus, appear. If there is sloughing, they become greenish or 
grayish, resembling spinach, or reddish-brown and very liquid or pul- 
taceous. The odor is penetrating and offensive. Shreddy masses of 
necrotic tissue are discharged. Gray liquid movements, somewhat 
slimy, contain more pus than the others. Small opaque, or translu- 
cent, gelatinous grayish masses, one to three cubic millimetres in diam- 
eter, are found in the stools. 

In the more moderate types the stools at the outset are like those of 
gangrenous dysentery if the attack is abrupt. If gradual, the stools 
are faecal, liquid, containing mucus and streaks of blood and many of 
the gelatinous grayish masses. Stools of this character number from 
four to ten in twenty -four hours ; this may continue for weeks. During 
the exacerbations the stools resemble those of the second period of the 
gangrenous form. In chronic dysentery there is not so much mucus 
or blood, except in exacerbations. The stools are of the consistence of 
thin gruel and have an earthy or dull-yellow color. Mucus is persist- 
ently present, however, in the intermissions, when the stools are soft 
and faecal. 

The reaction of dysenteric stools is generally alkaline. 

Microscopical Examination. In the mucoid and bloody stools 
of the acute stage red blood-corpuscles, leucocytes, and large, round, 
or oval epithelioid cells are seen. The latter are often in groups of 
three or more. The nucleus is about the size of the red blood-corpus- 
cle, the protoplasm granular. Their outline is sharp. They may be 
taken for amoebae. They are non-motile and refract light less strongly. 
Cercomonas intestinalis is present, but bacteria are not abundant. In 
the later periods the cell-elements are less numerous ; shreddy and 



344 GENERAL DIAGNOSIS. 

muscular detritus and bacteria are observed, with elastic-tissue fibres. 
Charcot's crystals and phosphates are seen. In chronic dysentery the 
cell-elements are still fewer and amoebae are easily detected. 

Amoeba Dysenteeje. Amoebae are found at all periods of the dis- 
ease. They vary in different cases and at different periods in propor- 
tion to the severity of the intestinal ulceration. (See section on the 
Faeces.) 

They are most abundant in the grayish-yellow gelatinous masses, 
next in the particles of clear or opaque mucus, and least in the fluid 
portions of the stools. In chronic dysentery they are found in all 
portions. In the intermission of the diarrhoea they may be found in 
the particles of mucus adherent to the faeces. They disappear as recov- 
ery proceeds, although they may be seen after the evacuations become 
normal. They vary in size and activity. They are more common in 
the alkaline and neutral stools. They are scarce and are rarely motile 
in acid stools. In the more active forms of the disease red corpuscles 
are seen. 

For the detection of amoebae the following should be observed : 
First, the stools should be passed in a warm bed-pan and kept at a 
temperature of 30° to 35° C. until an examination is made. Second, 
the stools must be examined before they become acid. Third, the 
gelatinous masses in the stools should be selected for examination. 
They contain amoebae in greatest abundance. A magnifying power of 
four hundred diameters is required, although they may be seen with less. 
A y 1 ^- oil immersion lens is the best. 

Desceiption of the Amcebje. When inactive they are round or 
slightly oblong, highly refractive, and contain vacuoles of greater or 

Fig. 88. 




Amoebae coli. (Hallopeau.) 

less size. The latter are clear, and vary from small points to one-third 
of the diameter of the areola. The ectosarc and endosarc may or 
may not be sharply divided. If they are, the outer is hyaline or 
homogeneous, the inner is more refractive and contains vacuoles. 
They are difficult to recognize in this condition, being mistaken for 
swollen connective-tissue cells. The amoebae frequently enclose red 



THE DATA OBTAINED BY OBSERVATION. 345 

corpuscles, pus-cells, blood-pigment, bacilli, and micrococci. In a 
fresh state the nuclei cannot be made out because they resemble vacu- 
oles. The endosarc is not granular, is composed of a dense substance, 
and is highly refracting. When active the movement is characteristic. 
It may be slow or rapid, and is of two kinds, a progressive movement 
and one limited to the throwing out of pseudopodia. The movements 
appear to be rhythmical in some cases, occurring at regular intervals. 
The movement is sudden and characterized by change in form of the 
pseudopodia. The ectosarc and endosarc are clearly defined usually. 
The pseudopodia are hyaline and homogeneous, like the ectosarc. 
The amoeba changes its position sometimes by enlargement of the 
pseudopodia, into which the inner contents of the older part follow. 
The movements are increased when the examinations are made on the 
warm stage. These amoeba? may be stained with various aniline dyes. 

In catarrhal dysentery the stools are uniform in character, quantity, 
and frequency. The onset is sudden, and evacuations consist of bright 
blood and viscid, clear mucus mixed with faecal matter. Soon they are 
composed entirely of mucus and a little blood. The mucus is viscid. 
In a week or ten days the mucus changes and becomes grayish-white 
in color — is less blood-stained and brown ; pultaceous or fluid faecal 
matter appears in the stools. As the blood and mucus disappear 
formed faeces return. In the prolonged cases there are soft, yellowish- 
brown, or greenish stools in addition to the bloody mucoid stools. 
The frequency is greatest at the onset, and progressively diminishes 
until convalescence is established. The more frequent the evacuations 
the smaller the size of the stools. The mucoid stools are small, pulta- 
ceous, more bulky. On microscopical examination red and white cor- 
puscles, cylindrical, epithelial, and oval epithelioid cells are seen. The 
latter are very characteristic, and occur singly or in groups. Bacteria 
are more common as improvement sets in. In the pultaceous stools 
the cell-elements are scarce. In diphtheritic dysentery the stools are 
watery. They resemble wheat-washings — evacuations such as are de- 
scribed in cases of gangrenous dysentery. They are grayish-green or 
reddish-brown and very offensive. Mucus is present in small amounts. 
At first unclotted blood is present, afterward minute dark-red clots are 
seen. Shreddy and finely divided material, gray or reddish-brown in 
color, is present, but there are no sloughs. The stools are not numer- 
ous at first, and average from seven to fifteen daily during the course 
of the illness. The quantity passed is small. Cylindrical epithelial 
cells are most abundant on microscopical examination. Red blood- 
corpuscles and leucocytes are observed, but fibrin constitute the larger 
portion of the stool. In all the stools bacteria are present in great 
numbers. 

Other Symptoms of Amcebic Dysentery. Abdominal pain is 
constant ; it occurs in the early stages of both forms and in acute 
exacerbations. As the movements diminish the pain decreases. In 
the gangrenous form pain also disappears, although the intensity of 
the process is increasing. In chronic cases the colic is complained of 
during the exacerbations ; during the intervals a dull, aching, or burn- 
ing pain is complained of in the upper quadrants. In all cases the 



346 GENERAL DIAGNOSIS. 

pain is cramp-like, boring or burning in character, and usually pre- 
cedes and accompanies movements of the bowels. When severe it is 
general ; but it is usually localized in the lower abdominal zone. 
Moderate tenderness on pressure is present in most cases along some 
part of the course of the large bowel. In catarrhal dysentery tenesmus 
is common ; in the amoebic form it is infrequent. A burning sensa- 
tion in the rectum and at the anus during and after the passage of 
faeces is generally complained of. Nausea and vomiting occur at the 
outset or at irregular intervals, being caused by improper food, or due 
to complications. Hiccough occurs in the terminal stages. 

Fever. In amoebic dysentery fever is not a prominent feature, 
although there is usually a moderate rise in temperature. In the 
gangrenous form it is normal, or may be subnormal for days. Chronic 
dysentery is afebrile. In exacerbations of diarrhoea slight fever may 
occur. Complications cause a higher temperature. If fever is present 
it may be remittent or intermittent in character, or, if the illness is 
prolonged, first continuous, then remittent, and then intermittent. If 
the latter, the usual morning fall is observed, although an inverse 
temperature may be present. Rigors occur with the complications. 
Sweating is observed, with subnormal temperature, in the gangrenous 
form. In cases of abscess the fever is intermittent or remittent. 

In chronic dysentery the skin is excessively dry. The circulation 
and respiration are influenced by the pyrexia. Anaemia is pronounced. 
When exhaustion ensues the pulse becomes more feeble, compressible, 
and rapid. The urine is albuminous, and often contains casts. In the 
gangrenous form there may be retention of urine. 

The complications of amoebic dysentery are : 1. Hepatic abscess, 
or hepato-pulmonary abscess. 2. Peritonitis. 3. Hemorrhage from 
the bowels. 

Hepatic Abscess. This complication may develop at any period 
of the disease. The time of the disease when it occurs cannot be deter- 
mined definitely. In the subacute cases it is liable to develop from the 
fourth to the twelfth week. The abscess may develop on the convex 
surface of the right lobe of the liver near the coronary ligament. In 
these cases the lung also becomes involved. Councilman and Lafleur 
suggest that infection takes place by the peritoneum. (See Abscess of the 
Liver.) While the symptoms of abscess of the liver will be treated 
under the section devoted to liver disease, it is important to note that 
hepatic symptoms may occur in cases in which, on account of the mild- 
ness of the disease, the local bowel trouble may be overlooked entirely. 
(See Amoebic Abscess of Liver : Musser and Willard, Phil. Co. Med. 
Soc.) If the association of hepatic pain with fever and discharge of 
mucus from the bowels is observed, it is barely possible, even if an 
examination of the faeces cannot be made, that a hepatic abscess is 
present. If, in addition, cough and expectoration occur, involvement 
of the lungs is possible. 

Hepato-pulmonary Abscess. The character of the expectoration 
points conclusively to the nature of the lung complication. After a 
period of dry, hacking cough, sudden expectoration of mucopurulent 
or bloody sputum takes place. It is of a dirty-red or brownish color, 



THE DATA OBTAINED BY OBSERVATION. 347 

not unlike anchovy sauce. From this time on this material is expec- 
torated in varying quantities after a paroxysm of coughing. The expec- 
toration is diffluent, tenacious, and frothy. It varies in color from 
bright red to russet-brown ; it may be bile-stained. The sputa are 
alkaline ; the odor is not putrid. At a later period they become more 
purulent, and contain less blood. The sputum separates into three 
layers : an upper frothy layer, a middle layer of turbid fluid, a thin 
layer of mucopus below. Large amounts may be coughed up in 
twenty-four hours ; the sputa contain, on examination, blood-cor- 
puscles, leucocytes, round alveolar epithelial cells and polyhedral, fatty 
degenerated cells, which look like liver-cells. Elastic-tissue fibres from 
the lungs are found with crystals of hsematoidin and tyroshi, and Char- 
cot's crystals. Bacteria are present. Amoebae are constantly present. 
They vary hi size and activity, but are larger than those seen in the 
stools. The sputum should be kept warm and examined as soon as 
possible. 

Peeitonitis. Peritonitis from perforation is not a common com- 
plication of amoebic dysentery, but takes place occasionally hi the gan- 
grenous form. Peritonitis without perforation may occur. The 
symptoms do not differ from peritonitis under other circumstances 
Hemorrhage from the bowel occurs and may be sufficiently profuse to 
cause death. This accident may occur in the course of amoebic ab- 
scess of the liver, as in a case reported by the author, in which there 
were no intestinal symptoms. Other complications which have been 
described under catarrhal and croupous dysentery are likely to occur 
in this affection. 

The Diagnosis. The diagnosis of amoebic dysentery is made abso- 
lute by finding the amoebae in the stools. The history and the course 
of the illness must also be taken into consideration, the characteristics 
of which have been previously detailed. The irregularity, and the 
intermittency of the diarrhoea, the infrequency of tenesmus, the mod- 
erate fever, the reaction of the stools, and their comparative freedom 
from bacteria, are further corroborative points. 

The Plague. 

This infection is seen in two forms : One, pestis major, is character- 
ized by inflammation of the glands of the body, known also as malignant 
adenitis. Another, pestis siderans, is attended by intense septicaemia, 
with or without hemorrhages. Unlike the first variety, the glands are 
not enlarged. It is divided, in accordance with its special features, 
into septicemic, pneumonic, gastro-intestinal, nephritic, and cerebral 
forms. 

It is an acute, specific, infectious, and contagious disease, occurring 
in epidemics, characterized by high fever, sometimes by petechias and 
other hemorrhages, and, in cases which last long enough, by buboes. 
The death-rate is extremely high. 

The plague is a disease of the East, being endemic in some parts of 
India, but epidemics have occurred in Italy, Russia, China, Turkey, 
England, and other parts of Europe. 



348 



GENERAL DIAGNOSIS. 



The period of incubation is from two to seven days. The invasion 
is marked by lassitude, languor, headache, and dizziness. The stupid 
aspect and staggering gait may lead to the belief that the patient is 
drunk. Chill or chilliness soon supervenes, followed by fever, which 
often rises to hyperpyrexia, and is accompanied by unquenchable thirst, 
and sometimes nausea and vomiting. Delirium and a typhoid condi- 
tion follow, with a marked tendency to failure of the circulation and 
collapse. If the patient survive until the second or third day, glandu- 
lar swellings develop in the groin, or axilla, or angle of the jaw. 
Often they have to be sought for to be found. Sometimes they are 
prominent and are followed by suppuration and even ulceration. Car- 
buncles are much rarer manifestations than buboes. Petechias, vibices, 
hemorrhages into the kidney, and bloody vomit, occur in the worst 
cases. 

Diagnosis. The diagnosis is based upon the history, the clinical 
course, and the results of bacteriological examination. The following 
description from Abbott enables the diagnosis to be readily made : 



Fig. 89. 
A 



'*r i Ci ■ "J 




£* ,»C» 




Bacillus of bubonic plague: A, iu pus from suppurating bubo; B, the bacilli very much enlarged, 
to show peculiar polar staining. (Abbott.) 

" This organism is described as a short, oval bacillus, usually seen 
single, sometimes joined end to end in pairs or threes, less commonly as 
longer threads. It stains more readily at its ends than at its centre. 
It is sometimes capsulated ; is non-spore-forming ; is aerobic, and is 
non-motile. It is found in large numbers in the suppurating glands, 
and in much smaller numbers in the circulating blood. (See Fig. 89.) 

" It is demonstrable in cover-slip preparations made from the pus 



THE DATA OBTAINED BY OBSERVATION. 349 

and in sections of the glands by the ordinary staining methods. Yersin 
states that it retains its color when treated by the method of Gram, 
while Kitasato says that it at one time stains by this method and at 
another it becomes decolorized. Aoyama observed that those bacilli 
within the suppurating glands were decolorized, while those in the 
blood retained the stain when treated by Gram's method." 

The duration is from six to ten days. If there is much suppura- 
tion, convalescence is prolonged. 

Leprosy. 

A chronic, specific, infectious disease, characterized by the develop- 
ment of tubercles, anaesthetic patches, and neuritis, and followed by 
ulceration and destruction of tissue. The disease occurs especially 
from puberty to the thirtieth year, and oftener in men than in women. 
It develops slowly and insidiously. Sometimes the first skin lesion is 
a crop of bulla?, suggestive of pemphigus. More commonly there 
appear reddish or violet-colored patches, varying in size from a quarter 
of an inch to two or three inches in diameter, and becoming of a darker 
hue later. The next step is the formation of nodules, which are char- 
acteristic of the disease. These may develop upon the patches already 
described, or in other places. They vary in size from a pea to a bird's 
egg or larger. They are most common upon the face and extensor 
surfaces of the arms, legs, fingers, and toes. The tubercles consist of 
an infiltration into the true skin ; they are raised, firm, relatively pain- 
less, and vary in color from red to copper. The face is characteristi- 
cally distorted into a fierce expression (leontiasis). The tubercles may 
become absorbed and leave atrophic areas, but generally they break 
down into eroding ulcers, which slowly burrow and increase in extent, 
eating off a portion of the nose, fingers, hands, and feet, and exposing 
muscles, tendons, nerves, bloodvessels, and bone. Tubercles form also 
upon nerve-trunks, and ulcers upon the mucous membranes. (See the 
Nose and Larynx.) 

In other cases, or in combination with the tubercles, especially upon 
the lhnbs and trunk, there are anaesthetic areas. Ulcers may follow 
without the previous occurrence of tubercles. With the anaesthetic 
patches are associated crops of bullae, and neuritis. 

The further peculiarities of the disease are : its long duration, its 
slow progress interrupted by apparent healing of some of the ulcers ; 
its afebrile course (the temperature is generally subnormal) ; its com- 
parative painlessness, and the slight impairment of the general health. 

Death results from gradual wasting, or is hastened by some intercur- 
rent affection. 

Diagnosis. The specific cause of the disease is probably the bacillus 
leprae of Hansen. It is found in the thin pus of the ulcers and in the 
lesions themselves. It consists of rods 4 to 6/i long and \fi broad, closely 
resembling tubercle-bacilli. They stain in alkaline fluids, but do not 
bleach after exposure to acids. Staining cover-slip preparations with 
the Ziehl-Neelsen fluid and decolorizing in acid and alcohol bring 
them out. They may be distinguished by yielding their color more 



350 



GENERAL DIAGNOSIS. 



readily, and bv taking easilv aniline-elves in simple watery solution 
(Yon Jaksch). (See Plate III., Fig. 4; b.) 

The diagnosis from a tubercular syphilide is made by the history of 
the case, the possibility of infection, the bacteriological examination, 
the slow progress, and the inadequacy of specific treatment. The pres- 
ence of anaesthesia and of neuritis points to leprosy. 



Actinomycosis. 

The general symptoms attending this infection are like those due to 
suppurative infections. The fever is irregular, often intermitting. 
It is a specific infectious disease of cattle, occurring occasionally in 
man, attacking especially the lower jaw, lungs, and intestines, and 
characterized by a long duration, by the development of tumors and 
metastatic growths, and by pycemic symptoms. 

It is due to the actinomyces, or ray-fungus (see Fig. 91), which pro- 
duces in cattle the disease known as big or lumpy jaw and swelled 
head. The fungus is conveyed in the food or drink, and gains entrance 
to the body through abrasions in the mouth or a decayed tooth, or is 
inspired into the lungs. Israel, Ponfick, and Bostrom have given us 
the greatest amount of information in regard to this parasite. It was 
discovered in 1845, in human beings, by B. v. Langenbeck, and in 
1877, in cattle, by Bollinger. 

Fig. 90. 




Case of actinomycosis. 



At the seat of invasion a slowly growing, slightly painful tumor 
develops. Bones are affected as well as soft tissues. These become 
swollen and suppurate, the fungus being at all times obtainable. The 



THE DATA OBTAINED BY OBSERVATION. 351 

fungous masses appear to the unaided eye as particles of yellow sand, 
and are greasy to the touch. 

Pulmonic Form. Actinomycosis of the lung may be divided into 
three stages : a latent stage, when the lung proper is affected ; an active 
stage, when extension to the pleura and chest wall takes place ; and a 
final or chronic stage, when perforation and the formation of a thoracic 
fistula occur and the adjoining organs become affected. The symp- 
toms of the first stage are those of chronic bronchial catarrh, with 
later the occurrence of the physical signs of consolidation, especially 
in the mamillary and axillary regions of the chest, in the middle zone 
of the thorax. The apices and bases are rarely affected primarily. 
The symptoms of the second stage are those of pleurisy, with adhesions 
and with or without effusion. At this time the disease may extend 
downward to the liver and peritoneum, or the pericardium may become 
infected. Fever and pain accompany these processes. On physical 
examination, in addition to the signs of the pulmonary and pleural 
conditions above mentioned, swelling of the thoracic wall will be ob- 
served, not unlike that of an empyema which is about to perforate. 
The swelling, which is at first dense, and hard, and red, becomes softer 
in small areas, and may fluctuate. Fluid, which is mucopurulent and 
shows the parasite, may be removed by aspiration. Repeated dry taps 
may occur before the needle secures the. serous or sanguino-serous exu- 
dation in the pleura. The sputa at this time may accidentally show 
the parasite, although this is rare. The expectoration is mucopuru- 
lent, but it is said to never contain elastic fibres. The course of the 
disease at this time may extend over many months, in contradistinction 
to empyema on the one hand or carcinoma on the other. In the final 
stage ulceration of the swelling is seen in many places, fistula forms, 
and the disease extends to adjacent structures. Secondary infection 
may occur and symptoms of pyaemia develop. 

The masses which form upon the intestinal mucous membrane may 
lead to suppuration and perforation of the intestine. Metastasis to any 
organ may occur, with resulting local symptoms. The duration depends 
upon the organs involved in metastases. If metastases do not lead to 
early death, that result is brought about at the end of months or years by 
slow pyaemia, with resulting amyloid degeneration and its consequences. 

It is usually associated with chronic inflammation and the produc- 
tion of pus. The pus is peculiar. It is thin and viscid. Small 
nodules of gray or yellow color, the size of a poppy-seed, can be seen 
by the naked eye when it is spread out on a glass. With a low power 
these particles are aggregations of spherules, which with a higher 
power are seen to be arranged in masses radiating from a common 
centre. Each separate spherule is pear-shaped. They have high re- 
fractive power. In the centre of the masses a network of fibres is 
seen. If the mass be broken up numerous club-shaped forms in the 
periphery are seen, while at the centre a sort of detritus alone is ob- 
served. The micro-organism belongs to the class of fission-fungi, and 
the club-shaped bodies are the degenerated forms. (See Fig. 91.) 

Gram's method of staining brings out the threads of the network 
most distinctly. The centre is made up of a network of minute spheri- 



352 



GENERAL DIAGNOSIS. 



cal organisms, with converging constituent threads. The whole is sur- 
rounded by a delicate envelope. The pear-shaped bodies may be 
denned by Weigert's process. Make a solution of 20 c.c. of absolute 
alcohol, 5 c.c. of concentrated acetic acid, 40 c.c. of distilled water, and 
sufficient French extract of litmus to color it ruby-red after repeated 
filtering. In this solution the cover-glass preparations are allowed to 
remain for an hour, and then rinsed with alcohol rapidly and placed 

Fig. 91. 





?j^i^;S^ r 




Actinomyces. 



11) 



a 2 per cent, gentian- violet solution for three minutes. The fluid 
should be boiled before use and filtered after cooling. The fungous 
threads are stained a ruby-red, while the central mass of actinomyces 
is colorless. 

Diagnosis. Simple microscopical examination is usually sufficient 
to determine the nature of the fungus. The recognition is more posi- 
tive if we bear in mind the peculiar character of the pus in which the 
nodules and the club-shaped forms are seen. It must not be mistaken 
for the radiating leptothrix threads found in the mouth. Pure cultures 
have been obtained resembling macroscopically the cultivation of the 
tubercle bacillus. 

Tetanus. 

Tetanus is an acute, infectious disease of the nervous system, the 
essential characteristic of which is persistent tonic spasm of the muscles 
of the jaws (lockjaw) and of the spinal and trunk muscles. The disease 
begins with the stiffness of the jaw, which steadily increases until, 
within a few hours, there is complete tonic spasm of the jaw. The 
neck-muscles, and then those of the spine and trunk, become rigid, so 
that the body is arched backward and may rest upon the heels and 
head (opisthotonos). The facial muscles share in the spasm, and by 
their contraction produce a horrid, grinning countenance (rims sar- 
donicus). The contracted muscles become painful, and there is also 
epigastric pain. The rigidity is persistent, but is interrupted by ex- 
acerbations in which the phenomena already described are exaggerated, 
and, in addition, respiration is embarrassed, the face becomes livid, the 
skin bathed in sweat, and the patient is further distressed by increased 



THE DATA OBTAINED BY OBSERVATION. 353 

pain in the affected muscles. The body may be bent forward (empros- 
thotonos) or laterally (pleurosthotonos). The temperature is not con- 
stant. It may remain normal, be moderately elevated, or hyperpyrexia 
may be present, especially toward and after the end in fatal cases. The 
spasm ceases during sleep, but subsequently returns. 

The cause of the disease is the bacillus of tetanus, which produces 
the convulsive poison tetanin. The bacillus is seen as a delicate, slen- 
der rod, with a terminal spore. It stains with aniline dyes and Gram's 
fluid. Cultivations may be made with the pus. It should be smeared 
over the surface of slanted agar-agar or blood-serum in a sterilized 
tube, placed at 37° C, for twenty-four hours, then heated to 80° C. in 
a water-bath from forty-five to sixty minutes. At the end of this time 
gelatin plates or Esmarch tubes are to be made from the growth in the 
heated tube ; these are to be kept in an atmosphere of pure hydrogen 
at 20° to 22° C. Growth is favored by the addition to the gelatin of 
2 per cent, of glucose. If the inoculation be made as a stab in a tube 
about three-quarters filled with gelatin, growth is seen only to within 
about 2 cm. of the surface of the media. Faint radiating strise or 
thorn-like processes are seen. The development is rapid in agar-agar. 
After an exposure of thirty hours to a temperature of 37° C. the 
spores make their appearance. On gelatin the colonies are dense at 
the centre, with a more delicate periphery. The preparation becomes 
fluid, and gas is evolved. It is strictly anaerobic. The accompanying 
illustration from Abbott's work on Bacteriology shows its appearance. 




Fig. 92. 



<< 



1 f 



a* 

B 

Tetanus bacillus, a. Vegetative stage, from gelatin culture, b. Spore-stage, showing 
pin-shape. (Abbott.) 

Tetanus frequently follows an injury. Trismus neonatorum and 
puerperal tetanus are names given to special varieties which occur in 
new-born children and in puerperal women. Tetanus is much more 
common in men than in women, and Gowers states that three-fourths 
of the cases occur between the ages of ten and forty. It is much more 
common in hot than in cold countries, though cold is an exciting cause. 

In traumatic and puerperal cases the disease usually develops in 
from a few days to two weeks from the time of injury or childbirth or 
abortion. In new-born children it occurs usually during the first week. 
It lasts from two to six weeks, but may be fatal much earlier, or, in 
rare cases, last even longer. 

Tetanus must be distinguished from strychnine-poisoning. In the 
latter the jaw-muscles are never involved early, if at all, and the mus- 

23 



354 GENERAL DIAGNOSIS. 

cles are relaxed between the paroxysms. It is distinguished from tetany 
by the history and the distribution of the spasm, which in tetany is 
confined to the extremities. Bacteriological methods should be re- 
sorted to. 

Trichinosis. 

Until recently fever was not looked upon as an attendant of the 
gross parasitic invasion which is considered below. The study of a 
large number of cases shows that fever is present in various forms. In 
not a few, it is true, it may be very slight for a few days, and then 
fall to normal, and even, especially in convalescents, be strikingly 
subnormal. In other instances the temperature curve may be markedly 
intermittent. The chart from Osier's monograph shows this peculi- 
arity. (See Fig. 93.) Finally, the fever-range is not unlike that of 
typhoid fever in many instances. Striimpell observes that the fever is 
seldom continuous for any length of time, and that its course is inter- 
rupted by frequent and prolonged intermissions. Niemeyer compares 
the curve to that of typhus, and Eichhorst to that of typhoid fever. 

The infection is acute, caused by absorption of trichinae spiralis, and 
characterized by fever, gastric and intestinal irritation, followed by 
pain and stiffness in voluntary muscles, oedema of the eyelids, face, 
and feet, by profuse sweating, and by death or tardy convalescence. 

The trichinae are absorbed by human beings through raw or imper- 
fectly cooked food, often in the form of sausage. The trichinae are 
encysted when absorbed, but within forty-eight hours they are liber- 
ated in the intestine and can be found adherent to the mucous mem- 
brane. In the course of six or seven days each liberated female worm 
produces about 180 embryos, Avhich immediately penetrate the walls 
of the intestine and travel or are carried to all parts of the body, 
becoming in turn encysted. 

Swallowing of trichinous flesh does not necessarily produce symp- 
toms ; the trichinae may be destroyed in the stomach, or, if calcified, 
may pass through the intestine unchanged. When symptoms result 
the severity depends upon the number of trichinae which become liber- 
ated. The symptoms are sleeplessness, lassitude, anorexia, nausea, 
vomiting, tenderness over the abdomen, and diarrhoea. Headache is 
a constant and marked symptom of invasion. Colicky pains attend 
the gastro-intestinal symptoms. These symptoms may not be marked 
in the beginning of the disease ; or they may be so severe as to cause 
death in two or three days. If the patient survive, toward the end of 
the week the voluntary muscles become stiff, painful, and contracted. 
The muscles feel hard and swollen. The eyelids, face, and sometimes 
the feet become oedematous. Depending upon the muscles involved, 
there are interferences with the eye-movements, contractions of the jaw- 
muscles, difficulty in breathing or in swalloAving, etc. The calves of the 
legs are especially involved. Recurrent oedema over the affected muscles, 
eyelids, and face is very common and characteristic. Profuse sweating 
also is very common, and at times there are severe neuralgic pains. 

The fever is usually moderate, but it may be high. It follows the 
types described above. It is accompanied by malaise, with pains in 



THE DATA OBTAINED BY OBSERVATION. 



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356 GENERAL DIAGNOSIS. 

the joints and muscles, preceding the true local muscle pain. The pulse 
is very frequent if trichinae reach the heart. The later stages in fatal 
cases are marked by insomnia, delirium, stupor, and coma. 

The duration varies from a few days to four or five weeks, or even 
longer. Muscular pains may persist for months after recovery. Death 
results from exhaustion, or from some complication, as pneumonia or 
ulceration of the large intestine. 

The Blood. Brown, in studying Dr. Osier's cases, found an increase 
in the leucocytes, and on a differential count a great increase of the 
eosinophiles. The leucocytes were increased to 17,000 per c.mm. 
The eosinophiles increased from 2 per cent., the normal, to 37 per cent., 
and at one time to 68.2 per cent. In subsequent cases their average 
increase was as high as 48 per cent. 

Diagnosis. The diagnosis is based upon the history, the peculiar 
muscular pains and swellings, the localization of the oedema, and the 
leucocytosis and eosinophilia. The muscles are swollen and hard, 
painful on pressure, and contracted. There is no involvement of the 
joints, an important point in the diagnosis. The oedema (see Chapter 
XL) is seen in the eyelids and over the eyebrows. It is of common 
occurrence over the swollen and tender muscles. It is distinguished 
from typhoid fever by the presence of vomiting, and oedema of the face 
and eyelids, the development of muscular troubles, by the absence of 
hebetude, delirium, and other typhoid symptoms, and absence of the 
characteristic eruption and enlargement of the spleen. 

Muscular rheumatism is distinguished by being limited to one part, 
as the lumbar region, arm, or chest ; by its appearance following ex- 
posure to draught ; and by the fact that it is not preceded by nausea, 
vomiting, and diarrhoea, nor accompanied by oedema. 






CHAPTER XXI. 

THE DATA OBTAINED BY OBSERVATION— {Continued). 

Exploratory puncture or aspiration for diagnosis: Instruments. Preparation of instru- 
ments. Preparation of skin. Point of puncture. —Exudations (Pus. Seropus. 
Gangrenous debris. Blood. Serum. Chyle): Pus. Blood-corpuscles Bac- 
teria. Protozoa. Vermes. Crystals. — Chemical examination: Seropurulent 
exudations. Putrid exudations. Hemorrhagic exudations. Serous exudations. 
Chylous exudations. Pleural effusions. Transudations. — The contents of cysts: 
Hydatid, ovarian, renal, pancreatic. 

THE EXAMINATION OF EXUDATIONS, TRANSUDATIONS, 
AND CYSTIC FLUIDS. 

Exploratory Puncture or Aspiration for Diagnosis. The presence 
or absence of fluids in the natural cavities of the body, as the peri- 
cardium, the pleura, or the abdomen, or in the gall-bladder, must 
frequently be ascertained by means of puncture or aspiration. The 
fluid is secured at the same time by the puncture for examination. 
The fluid of tumors or cysts is likewise withdrawn to complete a diag- 
nosis by determining its chemical, microscopical, or bacteriological 
character. Certain rules of procedure are necessary, and, as they are 
common to the method in whatsoever situation employed, may be con- 
sidered in this section. 

The Instruments. If it is the desire of the observer to determine 
the presence of fluid, an ordinary grooved needle may be used. If, 
however, fluid is to be obtained for examination, a syringe or aspirator 
must be used. An ordinary hypodermatic syringe, or the syringe of 
Pravaz, may be used if the needles are long enough. A special aspi- 
rator made for diagnosis by instrument-makers is the best. The 
needles are sufficiently long, the barrel large enough to hold sufficient 
fluid for any method of examination. If the diagnosis is to be fol- 
lowed by treatment by aspiration, the apparatus of Dieulafoy, or any 
equally perfect apparatus, may be used at once. 

Preparation of Instruments. The instruments should be ster- 
ilized in a steam sterilizer, or boiled. This does not apply to ■ the 
needles alone, but every portion of the instrument should be cleansed, 
because, for instance, the contents of the barrel of the syringe pass 
through the needle. After sterilization they should be carried to the 
patient in sterilized test-tubes plugged with cotton-wool. When not 
in use the needles should be kept in absolute alcohol and the syringe 
in carbolic acid solution, 1 : 20. Before using, the carbolic acid should 
be washed from the syringe and needle with boiling water ; they are 
then to be sterilized as described. Unless the carbolic acid is removed 
from the syringe its presence may serve as an antiseptic or disinfectant, 



358 GENERAL DIAGNOSIS. 

and thus interfere with the culture-tests, to which the material drawn 
is to be subjected. 

Preparation of Skin. The skin should first be cleansed with 
soap and water, then with alcohol, then with a solution of carbolic acid, 
1 : 20, or of the bichloride of mercury, 1 : 1000. After thorough 
cleansing the parts should be kept covered with a towel soaked in 
bichloride solution until the time of operation. At the time of punc- 
ture the surface should be made anaesthetic by ethylene chloride, the 
rhigolene spray, by ice and salt, or, in adults, by the Schleich method 
of subcutaneous anaesthesia. Care must be taken, if the patient is 
aged or poorly nourished, or the skin oedematous, not to freeze the skin 
too much, on account of the danger of local gangrene. 

The Point of Puncture. The points selected for aspiration 
depend upon the cavity to be explored or the situation of the cyst. 

The Pleura. To withdraw the fluid within the pleura it is best 
to select a point for aspiration in one of the lower interspaces of the 
chest, because the fluid is more likely to accumulate in this position 
and because complete aspiration can there be performed if necessary. 
The sixth or seventh interspace in the anterior axillary line, or the 
eighth or ninth interspace in the posterior axillary or scapular line, 
may be selected. On the right side the upper interspace of the two 
should be chosen on account of the position of the liver. If the con- 
tents tend to point or break out at any particular spot on the surface 
of the chest the puncture may be made in this area. In suspected 
loculated empyema or effusions the point of puncture should be at the 
site of greatest dulness and least fremitus. 

The Pericardium. For aspiration of the pericardium three points 
of election have been recommended : First, the usual position of the 
apex-beat, in the fifth interspace, inside of the midclavicular line ; 
second, the space between the ensiform cartilage and the left seventh 
cartilage, the point advised by Roberts ; third, Potch has tapped the 
fifth right interspace a number of times on the cadaver, and thinks 
that this situation is a proper one on the living subject. The writer 
has aspirated the pericardium in several instances inside of the normal 
position of the apex. Care must be taken to insert the needle slowly 
and with the point directed downward and toAvard the left axilla when 
this position is selected. 

The Abdomen. It should be remembered that no attempts at 
puncturing the abdomen should be made if pus is suspected, unless 
preparations have been made to perforin laparotomy at once. Indeed, 
this exploratory operation is performed with so little detriment to the 
patient by modern surgeons that, on the whole, it should be advocated 
instead of puncture. There are times, however, when the latter must 
be resorted to. The writer has performed it in a number of instances 
— always refusing to do so in cases in which pus was probably present 
in the peritoneal cavity, or in tumors, or in organs the seat of suppura- 
tion — without any danger having ever arisen. Explorations of this 
character are probably more feasible in connection with diseases of the 
liver. It does not appear to be harmful to insert needles into that 
organ, and valuable information is often gained thereby. 



THE DATA OBTAINED BY OBSERVATION. 359 

In aspiration of the abdomen, to determine the character of perito- 
neal contents, the median line should be selected for the puncture. The 
bladder must be emptied and a point midway between the umbilicus 
and pubes selected. 

The Vertebral Canal. Spinal or Lumbar Puncture. Proposed 
by Quincke, the procedure has been carried out by many clinicians and 
has proved to be a means of corroborating and even establishing a diag- 
nosis. Cerebral lesions are diagnosed and intracranial pressure relieved 
because of the continuity of the spaces in the brain and the spmal canal. 
(See Cerebro-spinal Meningitis.) 

Method. The patient should lie on the right side, with the knees 
drawn up and the left shoulder turned forward. The puncture is made 
by an antitoxin needle or the needle of a large hypodermic syringe, 
which may then be used to withdraw the fluid. The syringe itself 
may be removed and the fluid allowed to ooze through the needle drop 
by drop. A needle 4 cm. in length and 1 mm. in diameter is suitable 
for infants ; a longer needle for children over ten and adults. The 
point selected for puncture is midway between the third and fourth or 
fourth and fifth lumbar vertebra?, below the spinous process, a little 
to one side of the median line. The thumb of the left hand of the 
operator placed between the spinous process may be used as a guide. 
If the needle is inserted to the right of the median line, preferably on 
this side, it should enter 1 cm. from the median line, on a level with 
the thumb, and be directed slightly upward and inward. At a depth 
of 3 or 4 cm. in children and 7 or 8 cm. in adults the canal is entered. 
The fluid oozes drop by drop, and should be collected in a sterilized 
test-tube. It should not run down the sides of the tube. Five to 
fifteen cubic centimetres should be withdrawn. 

The fluid is examined chemically, bacteriologically, and microscopi- 
cally. Sugar has been found in brain-tumor and not in meningitis ; 
albumin is said to be less in the former than in the latter. In tubercu- 
lous meningitis the fluid is usually clear and limpid ; in other forms 
cloudy and turbid. Pus has been withdrawn in leptomeningitis. Blood 
may be found in hemorrhage into the lateral ventricles. The respective 
affection is distinguished by the results of bacteriological examination. 

Cover-glass preparations are made of the fluid and cultivations taken 
at once. In purulent meningitis streptococci, staphylococci, the pneu- 
mococcus, and the meningococcus (diplococcus intercellularis) may be 
detected. In tubercular meningitis tubercle bacilli have been found, 
especially after sedimentation. After the fluid has been twenty-four 
hours in a conical glass the fine clot which forms should be examined 
for bacilli. The absence of bacilli does not exclude tuberculosis. The 
positive result, however, is diagnostic. 

Inoculation, as in a case by Lafleur, will cause tuberculosis in a 
guinea-pig, and is diagnostic. A clear fluid does not exclude purulent 
meningitis ; usually, however, the fluid is purulent, turbid, or rich in 
leucocytes. 

Sometimes, although the canal is entered, fluid is not secured, be- 
cause the needle enters pseudomembrane, thick pus, or gelatinous fluid, 
or because fluid is retained in the lateral ventricles. 



360 GENERAL DIAGNOSIS. 

Cysts or tumors, with fluid contents, should be punctured over the 
point which presents externally, at which place it is evidently in closer 
proximity to the external wall. 

The Spleex. The spleen has been punctured for therapeutic and 
diagnostic purposes. If the organ is hard, as in chronic malaria, it 
may be done without danger ; but if it is enlarged and soft, as in infec- 
tious diseases, such as typhoid fever, it is hardly justifiable to puncture 
it, because of the danger of subsequent rupture. Risks attend the 
puncture of other organs, as the kidney. The writer has seen a serious 
hemorrhage follow such puncture, and, of course, septic inflammation 
may arise. Exploratory operation is more suitable for determining its 
condition. 

The Examination of Fluids and Discharges. While the fluids to 
be examined can be obtained by the above-mentioned method, it some- 
times happens that they are discharged spontaneously, as in the case 
of an empyema. 

The following general methods apply to the examination, in Avhat- 
ever way material is obtained. When derived from the natural cavi- 
ties they are known as exudations or transudations. Fluids are also 
obtained from cysts, but do not require different methods of exami- 
nation. 

The naked-eye appearances are first noted ; then microscopical ex- 
amination with and without staining is resorted to. . Chemical exami- 
nation is also required. Often culture-preparations and inoculations 
must be resorted to, as in the case of pus or of serous exudation. 

The Exudations. 

They may be composed of pus, seropus, gangrenous debris, blood, 
or pure serum or chyle. When pus, seropus, or putrid fluid is with- 
drawn, it implies absolutely an inflammatory origin. Blood and serum 
may be associated with inflammation, simple or infectious ; but may 
also point to impediments in the general or lymphatic circulation. 
Blood or bloody serum is thought to be of tuberculous or cancerous 
origin. Its absence does not imply the absence of either disease. A 
chylous exudation is usually due to obstruction of the lymph-channels. 

Purulent Exudations. 

Pus ranges in color from gray to greenish-yellow. It is turbid, of 
high specific gravity, and alkaline. It varies in consistence. When 
standing after removal it separates into two layers ; the upper layer is 
light yellow and transparent, and the lower opaque. Pus may be 
mixed with blood, and is then reddish-brown. (See Abscess of the 
Liver.) When it has undergone decomposition it is thin, green, or 
brownish-red, of a penetrating odor. 

Microscopical Examination : White Corpuscles. If the speci- 
men is fresh the cells exhibit the movements that are common in 
leucocytes. If a solution of iodine and iodide of potassium is added 
to them they change to mahogany color. If the pus is old and the 



THE DATA OBTAINED BY OBSERVATION. 361 

cells are dead, they are shrunken and granular. Enormous giant-cells 
and cells loaded with fat are seen in pus. 

Red Corpuscles. In fresh pus red corpuscles are also seen along 
with blood-pigment or hsematoidin-crystals. 

In addition to the corpuscles free fat-globules and fat-particles are 
seen. Epithelium is rarely seen. In the pus from the pleural cavity, 
if cancer is present, the vacuolated epithelial and endothelial cells 
sometimes seen in cancer may be observed. 

Bacteria. Micro-organisms are always detected with the aid of 
staining-methods. (See Chapter XVII., Bacteriological Diagnosis.) 
The micro-organisms are usually the determining cause of the suppu- 
ration. Suppuration, however, may be caused by chemical substances, 
although this is at least of rare clinical occurrence. Of the various 
fungi found the micrococci and bacilli are the most numerous. The 
commonest of these are the staphylococcus pyogenes aureus and strep- 
tococcus pyogenes ; the amoeba dysenterica, in abscess of the liver and 
secondary abscess of the pleura and lung. It was found in an abscess 
of the jaw by Flexner. For further description of the pyogenic micro- 
organisms, see below and Chapter XVI., The Infections. 

The Pyogenic Bacteria. 1. Staphylococcus Pyogenes Aureus. 
This micro-organism is found in acute abscesses and boils, sometimes 
also in infectious osteomyelitis and ulcerative endocarditis. In addi- 
tion to other portals it may enter the tissue through abrasions or the 
hair-follicles. 

Morphology. In cover-glass preparations they appear as small 
round bodies scattered among the pus-cells, rarely within them, single, 
in pairs or in clusters. They stain readily with the basic aniline dyes. 
(See Fig. 94.) 

Biological Properties. It is aerobic, facultative anaerobic, grow r s 
in milk, meat-infusions, gelatin, or agar at 18° C. Death-point is 56° 

Fir. 94. 




-M'^ 



Pus with staphylococcus. X 800. (Flugge.) 



to 58° C. after ten minutes' exposure. Growth. Make plate-cultures 
on agar-agar. After tw T enty-four hours in the incubator the plate will 
be studded with yellow or orange-colored colonies, round, moist, and 
glistening. In a gelatin stab-culture liquefaction occurs in thirty-six 
to forty-eight hours along the puncture, forming a funnel. The whole 
mass gradually liquefies. At the bottom of the funnel the microbes 



362 GENERAL DIAGNOSIS. 

collect as an orange-colored mass. On potato it grows as a brilliant, 
orange-colored, somewhat lobnlated layer. The growth gives off an 
odor of sour paste. (See Plate VII., Fig. 3, and Plate III., Fig. 2, b.) 

2. Staphylococcus Pyogenes Albus. It is also found in acute 
abscesses, but less often than the " aureus/ 7 and is less virulent. 

It is morphologically identical with the " aureus," but develops no 
pigment. The surface-cultures are milk-white, and the mass at the 
bottom of the liquefy mg gelatin is white. 

3. Staphylococcus Epidermidis Albus (Welch) closely simulates 
the staphylococcus pyogenes albus. It is the most common micro- 
organism on the surface of the body, and is often present in parts of 
the epidermis too deep for disinfection, save by heat. It is supposed 
to be the usual cause of " stitch-abscess." 

4. Streptococcus Pyogenes. It is found in acute abscesses, ery- 
sipelas, otitis media, puerperal metritis, infectious endocarditis, pseudo- 
diphtheria, scarlatinal angina, and most purulent inflammations of a 
phlegmonous character. It is the organism most commonly found in 
inflammations having a spreading tendency. 

Morphology. Cover-glass preparations show spherical cocci of 
varying sizes, which form chains of four to twenty elements, the chains 
often forming tangled masses. It is stained by the basic anilines or 
by Gram's method. (See Fig. 95.) 

Biological Properties. Grows in most media at a temperature 
of 16° to 37° C. (best 30° to 37°), but not on potato. It is facultative 
anaerobic, and does not liquefy gelatin. On plates it forms a flat, 
transparent disk of about one-half millimetre diameter. In stab-cul- 
tures it grows all along the puncture and forms a white opaque granu- 
lar column. The death-point is 52° to 54°, ten minutes' exposure. 
(See Plate VII., Figs. 1 and 2.) 

Fig. 95. 




Streptococcus pyogenes in pus. X 800. (FlxJgge.) 

Inoculated, it causes erysipelatous or phlegmonous inflammation. 

5. The Tubercle Bacillus. This is seen at times in pus removed 
from phthisical cavities, and the pus of abscesses, particularly about 
glands. It may be detected by methods of staining adopted in the 
examination of the sputum. Pus may be of tubercular origin, and the 
micro-organisms may not be detected by the usual microscopical 
methods. Its absence, therefore, does not imply the absence of tuber- 
culosis. Culture-methods and inoculation should be resorted to, partic- 
ularly the latter. 



THE DATA OBTAINED BY OBSERVATION. 363 

6. The Bacillus of Syphilis. The pus under these circumstances is 
usually derived from ulcers or inflammations, or from secretions about 
the vulva or prepuce. The actual relationship to syphilis has not been 
demonstrated. 

Lustgarten's method is as follows : After immersion for twenty-four 
hours at the ordinary temperature in the gentian-violet fluid of Koch- 
Ehrlich, the cover-glass preparation is removed and washed for a few 
moments with absolute alcohol. It is then placed for ten seconds in 
a 1 per cent, or 2 per cent, solution of permanganate of potash ; a 
watery solution of pure sulphurous acid is then poured over it, after 
which it is washed in water. If the preparation still shows its color, 
it must be reimmersed for a few seconds in the potash solution and 
then in the sulphurous acid, and again washed with water. 

7. Actinomyces. 

8. The Bacillus of Glanders. 

9. The Bacillus of Anthrax. 

10. The Bacillus of Leprosy. 

11. The Bacillus of Tetanus. 

12. The Bacillus of Influenza. (See Sputum.) 

13. The Micrococcus Lanceolatus. The Pneumococcus. The 
pneumococcus is often found in the pus of empyema and pericarditis, 
whether from the pleural cavity or after it has burrowed from this 
situation. It occurs in cerebro-spinal meningitis. It is easily detected 
by the usual staining-methods (for which see Sputum). 

14. The Bacillus Ooli Communis. The bacillus coli communis is 
found more commonly in infections within the abdominal cavity. (See 
Fseces.) 

15. The Gonococcus. It is constantly present in virulent gonor- 
rhoeal pus, usually within the pus-cell or attached to the surface of 
epithelial cells. Morphology. Micrococci, usually joined hi pairs or 
fours, flattened and separated, when stained, by an unstained intercel- 
lular space. Stains easily with anilines — not by Gram's method. 

No other cocci are of the same shape, and at the same time within 
the cells, except one which, however, stains by Gram's method. (See 
Plate III., Fig. 3, b.) 

Growth. Does not grow readily on ordinary media, but can be 
cultivated on blood-serum and other special media, such as urine, agar, 
etc. ; 30° to 40° C. is best, and a moist atmosphere is needed. Growth 
is slow and often fails. Forms a thin, scarcely visible layer, with 
smooth, shining surface, gravish-vellow by reflected light — is aerobic. 
(See page 308.) 

Protozoa in the Pus. Cercomonads have been observed in the pus 
of an empyema, probably from the lungs. Flexner has found the amoeba 
dysenterica in the pus of an abscess of the jaw. It is found hi abscess 
of the liver and secondary abscess of the lung. (See Sputum and Faeces.) 

Vermes. Filaria have been found in abscess of the liver. In the 
suppuration of hydatids the pus contains membrane and hooklets. 

Crystals. Crystals of cholesterin are found in the pus from cold 
abscesses, suppurating ovarian cysts, and foetid discharges. They are 
similar to the crystals described under sputum. 



364 GENERAL DIAGNOSIS. 

H^ematoidin-crystals indicate a previous hemorrhage ; they are 
most frequent in suppurating hydatid cysts. (See Fig. 96.) Fatty 
needles are found in old pus and gangrenous exudates. (See Fig 97.) 
Triple phosphates are frequently seen in pus, and are of the same appear- 
ance as the phosphates in the urine. The carbonates and phosphates 
are seen in foetid pus. 

Fig. 96. Fig. 97. 



#. H* . ^ // 





Pus from putrid empyema. (Eye-piece 
Rhombic crystals of hsemin. (Charles.) III., obj. 8, A. Reichert.) Shrunken leu- 

cocytes. Fat-crystals. (Von Jaksch.) 

Chemical Examination of Pus. This does not yield any informa- 
tion of diagnostic value. 

Serum-albumin, globulin, and peptone are detected by methods em- 
ployed in the examination of urine. Fresh pus contains sugar. After 
being boiled with an equal weight of sulphate of soda and filtered the 
filtrate is examined by the reagents used in examination of urine for 
sugar. Pus also contains bile-pigments and biliary acids, cholesterin 
and salts of sodium and the fatty acids in jaundice. Von Jaksch has 
found acetone in pleural exudations. 

Seropurulent Exudations. They resemble purulent discharges, 
chemically and morphologically. They point to antecedent inflam- 
mation. 

Putrid Exudations. The exudations are brown or brownish-green 
in color. The odor is penetrating and offensive. They are usually 
alkaline in reaction. On microscopical examination old leucocytes and 
crystals of fat, cholesterin, and hsematoidin are seen ; fission-fungi of 
various forms are seen. (See Figs. 96 and 97.) 

Hemorrhagic Exudations. Hemorrhagic exudations contain red 
blood-corpuscles and haemoglobin in large amount. Fatty endothelial 
cells are found. Quincke states that when the glycogen -reaction is 
shown, if the fluid is from the pleura, carcinoma is probably present. 
A positive diagnosis depends upon the discovery of the epithelial cells 
(see page 364), which are seen in cases of cancer. Hemorrhagic exuda- 
tions in the pleura are due most frequently to cancer, to tubercle, or to 
scurvy. To determine its exact nature (as to tubercle), inoculation 
and cultures are sometimes necessary. 



THE DATA OBTAINED BY OBSERVATION. 365 

Serous Exudations. 

The fluid is clear and light yellow or straw-colored. On standing a 
white fibrinous clot is deposited. On microscopical examination, red 
blood-corpuscles, leucocytes, fatty globules, and endothelial cells are 
found. They may be bunched in groups or scattered about. The 
micro-organisms, if present, are detected with difficulty. If ulcerating 
tuberculosis of the pleura is present the bacillus may be found, but 
tuberculous pleurisy may exist without ulceration, and hence the fluid 
is clear of the bacillus. Cholesterin-crystals are found in old serum. 
On chemical examination the fluid contains more than 3 per cent, of 
serum-albumin and globulin ; peptone is absent in pleural exudations ; 
sugar in small amount and acetone are found. 

The specific gravity of the fluid is above 1018. 

Chylous Exudations. True chyle is found in fluids of low specific 
gravity. Such an effusion is rich in fat and is due to leakage of 
lymphatics into the peritoneal cavity. It is known as a chylous effu- 
sion. Chyliform effusion is a term applied to the second variety of 
effusions mentioned in this section. The fluid has the property of 
chyle. Sometimes in peritoneal exudation, particularly if the patient 
has been upon a milk-diet, the fluid contains fatty matter, which gives 
it a milky appearance. The same character of fluid is seen in obstruc- 
tion of the thoracic duct. 

Special Effusions. Effusions in the Pleuka. It is of the 
greatest importance to distinguish the various forms of infection. 
Bacteriological examination is often necessary. In purulent exuda- 
tion, if micro-organisms are absent (staphylococcus and streptococcus), 
it is probably tuberculous ; serofibrinous exudations are usually free 
from fungi. When the micrococcus lanceolatus is found it is of favor- 
able prognostic omen. 

To distinguish the effusion of inflammation from that of transudation 
(obstruction) the specific gravity is of service. In the inflammatory 
effusions the specific gravity is high ; they also contain a large amount 
of fibrin and more than 3 per cent, of albumin. 

Transudations. 

This class of fluids is serous, bloody, or chylous. The specific grav- 
ity is lower than in inflammatory effusion. The color is light and the 
reaction usually alkaline. On microscopical examination but little is 
found. In pleuritic effusions there may be considerable endothelium, 
which, if mixed with blood, may be due to carcinoma. Serum contains 
albumin and sugar, the former in great excess. Peptone is always 
absent. The fluid coagulates with difficulty on boiling. 

Puneberg 1 lays stress upon the diagnostic importance of the amount 

1 Runeberg (J. W. ) : On the Diagnostic Importance of the Amount of Albumin in 
Pathological Transudations and Exudations. Berliner klin. Wochenschrift, 1897, 
No. 33. 



366 



GENERAL DIAGNOSIS. 



of albumin in pathological transudations and exudations. His experi- 
ence warrants the following statements : 

1. Inflammatory processes, 4 to 6 per cent, of albumin. 

2. Venous stasis, 1 to 3 per cent, of albumin. 

3. Marked kydrsemic conditions, as in amyloid degeneration or 
nephritis, 0.1 to 0.3 to 0.5 per cent. 

4. Combination of two or three of the above causes, 0.2 to 6 per 
cent. 

In group two, even without inflammatory complications, a high per- 
centage may occur in old transudations. 

Contents of Cysts. 

In aspiration of the abdomen and of the pleura cysts are sometimes 
evacuated, the nature of which is often determined by an examination 
of the fluid. It is within the province of this work to discuss hydatid 
cysts, pancreatic cysts, and the cystic kidney. As tumors of the ovary 
so frequently resemble tumors in other situations, it is well also to 
discuss in this section the nature of the fluid withdrawn from them. 

Hydatid Cysts. The fluid of hydatid cysts is clear, alkaline, and 
of a specific gravity of 1010. It contains chloride of sodium in ex- 
cess, grape-sugar in small amount, and very little, if any, albumin. 



Fig. 




Contents of an ovarian cyst. (Eye-piece III., obj. 8, A. Reichert.) a, squamous epithelial cells ; 
b, ciliated epithelial cells ; c, columnar epithelial cells ; d, various forms of epithelial cells ; e, fatty 
squamous epithelial cells ; /, colloid bodies ; g, cholesterin-crystals. (Von Jaksch.) 

On microscopical examination booklets are found, as in the sputum 
from hydatid cyst of the lung, as well as portions of membrane. The 
membrane is recognized by its peculiar transverse striation and the 
granular appearance of its inner surface. The heads or scolices are 
sometimes found. Two circles of hooklets and four disks on the ante- 



THE DATA OBTAINED BY OBSERVATION. 367 

rior aspect cross the head, which is separated from the hinder part by 
an annular constriction. (See Sputum and Faeces.) If suppuration has 
taken place the original nature of the cyst cannot be made out unless 
hooklets are found. After the fluid has been standing in a conical 
glass vessel the bodies may be found in the sediment. 

Ovarian Cysts. The fluid from an ovarian cyst is of high specific 
gravity, 1026, of alkaline reaction, contains but a small amount of 
albumin, and does not coagulate. On microscopical examination vari- 
ous forms of epithelial cells are seen, colloid bodies, and cholesterin- 
crystals. If hemorrhage has taken place in the cyst the color of the 
fluid is correspondingly changed, and beside the squamous, columnar, 
and ciliated varieties, some epithelium in the stage of fatty degenera- 
tion and red and white blood-corpuscles are seen. In colloid cysts 
the usual concretions are found. (See Fig. 98.) 

In dermoid cysts, in addition to the above, squamous epithelium, 
hairs, and fatty-, hsematoidin-, and cholesterin-crystals are detected. 
Ovarian fluid, contains albumin and methsemoglobin, or paralbumin. 
The latter is detected by mixing a portion of the fluid with three times 
its bulk of alcohol. It is then allowed to stand for twenty-four hours, 
when it is filtered. The precipitate is removed and suspended in water. 
After filtering the filtrate is seen to be opalescent, and is tested as 
follows : 

1. On boiling no precipitate is formed, but the fluid becomes turbid. 

2. There is no change with acetic acid alone. 

3. The fluid becomes thick and of a yellowish tint when treated with 
acetic acid and ferrocyanide of potassium. 

4. There is a change to a violet color when treated with concentrated 
sulphuric and acetic acids. 

Some observers differ from the above statement in their description 
of the fluid of an ovarian cyst ; all agree as to the large number of cell- 
elements. At one time it was thought that the fluid contained a special 
cell, but this view has been abandoned. In rare cases the specific 
gravity may be lower than that of the fluid of ordinary ascites. A 
fluid of low specific gravity, with a small amount of albumin, is said 
to be characteristic of a cyst of the broad ligament. 

Cystic Kidney. The fluid from a cystic kidney can be recognized 
by the properties it derives from the renal secretion. Urea and uric 
acid in large amounts point to its true source. Renal epithelium is of 
the greatest diagnostic value. (See Urine.) If epithelium from the 
urinary tubules can be detected after the fluid has settled the diagnosis 
is absolute. (See Hydronephrosis.) It must not be forgotten that both 
urea and uric acid may be found in other cysts, as in those of the 
ovary, if they communicate with the urinary tract. 

Pancreatic Cysts. The fluid from cysts of the pancreas is of a 
specific gravity of 1012, but may be as high as 1028. It contains 
cholesterin-crystals in abundance, and blood or pigment. Serum- 
albumin is present, but metalbumin is not found. Three diastatic 
ferments are present : 

(1) If on examination for sugar the latter is found to be a maltose, 
its presence is of diagnostic significance. 



368 GENERAL DIAGNOSIS. 

(2) The most pronounced property of the pancreatic fluid, and that 
by which we are enabled to distinguish it from other fluids, is the 
power of digesting albumin without the presence of an acid. 

Boas (Deutsche med. Woehenschr., 1890, Bd. xvi. p. 1095) developed 
the method of examination. The fluid is to be added to milk. After 
the casein is precipitated the biuret-test is applied, as follows : Heat 
the substance with caustic potash and add drop by drop a 10 per cent, 
solution of sulphate of copper. If digested albumin is present the fluid 
assumes a reddish-violet color. No other cystic fluid can dissolve 
albumin in alkaline solution. 

It is not necessary that albumin or fibrin should be employed in 
performing this test, as it is sufficient to add milk to the secretion ; 
when in such cases the casein of the milk is precipitated, and the 
biuret test is applied to the resulting filtrate, and the test compared 
with a control-milk from which the casein has been removed (this can 
be done by adding very dilute acetic acid with constant stirring), the 
digestive property of the liquid under examination may be with cer- 
tainty determined. The peptone would not be precipitated with the 
albumin, and as all albumins give the same reaction as peptone with 
the biuret test, the albumin should be removed before applying the 
test. It is removed from the filtrate by a saturated solution of ammo- 
nium sulphate. Then test the resulting filtrate with the biuret test. 
Then compare with the control-test as above. 

(3) The pancreatic fluid also emulsifies fats. In large cysts, however, 
particularly if of long standing, the physiological properties of the 
pancreatic juice are sometimes wanting. 1 In the case referred to by 
Boas and reported by Karewski, the old age of the cyst modified the 
character of the fluid, and hence rendered its nature doubtful. More- 
over, in the exploratory puncture the stomach was penetrated. For 
two reasons the author advises against exploratory puncture. First, 
the age of the cyst is not known, hence an analysis would be mislead- 
ing. Second, the danger of puncturing other organs is too great. Ex- 
ploratory laparotomy is preferable. 

1 In a case operated on by Penrose the analysis of the fluid was as follows: Sp. gr. 
1025; reaction slightly alkaline ; serum-albumin; no metalbumin; diastatic ferment 
absent ; maltose absent. By Boas' method, power to digest albumin appeared to be 
great ; but when the albumin remaining in the filtrate was removed from the pan- 
creatic fluid, it failed to show that peptone was formed. The method, therefore, 
appears to be fallacious in this class of cases. The cyst was old, and the fluid no doubt 
lost its physiological properties. Cholesterin was present in enormous amount ; ty rosin- 
crystals were very scarce. 



CHAPTER XXII. 

THE BLOOD. 

The blood is a tissue, the origin, growth, and decay of the elements 
of which has been the source of the greatest interest. It was the tissue 
held responsible in days gone by for many diseases, the origin of which 
was not known, so that skin eruptions, scrofula, and other affections 
were known as blood diseases. At present we hold such affections 
only blood diseases which show a demonstrable change in the physical 
or morphological characteristics of the blood. There is either diminu- 
tion of the red cells, increase or diminution of the white cells, or dimi- 
nution of the haemoglobin. Strictly speaking, most of the blood dis- 
eases now so called are really diseases of the blood-making organs — the 
lymphatic glands or the spleen. It is interesting to note that as late 
as 1866, J. Hughes Bennett included under diseases of the blood leu- 
cocythaemia, chlorosis and anaemia, diabetes, the infectious diseases, 
rheumatism, gout, and scurvy. The most recent text-book divides the 
blood diseases into ancemia, with two subdivisions, and leuhcemia. Of 
course, no one thinks of considering the infectious diseases blood diseases 
any more than we think of considering typhoid fever an ulceration of 
the intestine. 

Although the blood diseases are thus limited, it is none the less true 
that the blood may be the only tissue by an examination of which we can 
determine the ailment from which the patient suffers. As has been 
previously related, many infections are recognized in this manner only. 

The symptoms of blood affections are due to the physical change in 
the blood and the effect of this altered blood upon the function or the 
nutrition of the organs. Many functional symptoms thus arising may 
be the first indications of blood disease, as dyspnoea or palpitation, 
both very common symptoms. The symptoms may be subjective or 
objective, or both. The recognition of the former comes from the 
history of the disease and the complaints of the patient. The latter, 
or the objective symptoms, are determined by the physical examination 
of the patient and the examination of the blood. 

We recognize scarcely any condition at the present day due to an 
increase of the bulk of the bloodor of the red cells. Plethora is hardly 
a clinical identity. The symptoms of blood diseases, therefore, are the 
symptoms of ancemia. In like manner, all the data obtained by inquiry 
are those which belong to some form of anaemia. 

THE DATA OBTAINED BY INQUIRY. 

The Social History. Generally speaking, women, patients of 
early age, who have been subjected to want or had unusual care, or 
faulty nutrition, are those most liable to anaemia. No family predis- 

24 



370 GENERAL DIAGNOSIS. 

position exists to a marked degree apparently, although it is well 
known that " pale people " are a family class. The previous history 
and the data to be elicited in investigating it are best appreciated by 
turning to the classification of the cause of anaemia in succeeding pages. 

The history of the disease is usually that of gradual onset, although 
sudden fright or any cause producing profound shock is said to cause 
acute anaemia. But the reader must again be referred to the para- 
graphs just mentioned. 

The subjective symptoms are general. Languor, debility, and 
fatigue are complained of. The patient with anaemia, may have one 
group of symptoms preponderate. Thus headache, vertigo, restless- 
ness, noises in the head, and neuralgias may be the most prominent 
symptoms. Again, dyspnoea and air-hunger may be the most dis- 
tressing, or cardiac palpitation may be the earliest symptom, with or 
without cardialgia. Then gastro-intestinal symptoms are suggestive, 
although not pathognomonic. The peculiar appetite of chlorosis is 
well known. The causeless vomiting of many forms of anaemia has 
often been described. The bowels may be constipated or loose, varying 
more particularly because of the difference in the cause of the anaemia. 
Ringing in the ears has been referred to, and flashes of light, spots 
before the eyes, and other visual phenomena may be complained of, and 
show their origin in the state of the blood. Other alteration of the 
special senses are not marked in the course of any of the anaemias. 
These symptoms may occur singly or are combined in varying degrees. 

THE DATA OBTAINED BY OBSERVATION. 

While diseases of the blood, and especially forms of anaemia, are 
recognized by an examination of the blood, much information can be 
secured by general physical examination. It is true no disease would 
be pronounced a blood affection unless that tissue is examined by the 
modern means of research. 

An examination of a case of anaemia includes a study of the appear- 
ance of the patient, the color or hue of the surface, and the occurrence 
of oedema. Both these subjects are carefully considered in the chapters 
devoted to them respectively. Examination of the eye-grounds should 
always be made, when the findings discussed in the Chapter on the 
Eye may be present, if the case is one advanced in its course. No 
consideration of anaemia can be made, however, without an examination 
of the organs thought to be engaged in the blood formation, hence the 
state of the glands and the size of the spleen are inquired into. 

Finally, as evidence of the presence of anaemia, we observe frequently 
cardio-vascular phenomena. The murmurs that are heard in the heart 
and bloodvessels in this disease are fully discussed in the Chapter on 
Diseases of the Heart, to which the reader is referred. 

Examination of the Blood. 

Normal Blood. Before a consideration of the examination of the 
blood, it may be well to review the elements of which the blood is 
composed. 



PLATE IX 



Fig. 1 



. - ^. 



^ 



Blood from Case of Pneumonia, showing Leucocytes. 

■ ■ 



Fig. 2. 















Normal Blood, showing Rouleaux and Leucocytes. 

base. 



THE BLOOD. 371 

The blood consists of corpuscles and serum. The corpuscles are 
four : (1) Red blood-cells or erythrocytes ; (2) nucleated red blood-cells ; 
(3) blood-plaques ; (4) leucocytes. 

The ordinary red blood-cells measure 3-2V0 inch ; the leucocytes, 
-2 5 0-0 inch. In an adult man the red cells number from 5,000,000 to 
5,500,000 to the cubic millimetre ; in an adult woman the number is 
usually less, being from 4,500,000 to 5,000,000. There are 8000 to 
10,000 leucocytes in a cubic millimetre of blood, or 1 to 350-600 red 
blood-cells. 

Varieties of Leucocytes. In the normal blood there are found the 
following varieties of leucocytes : 1. Small mononuclear forms, which 
are cells about the size of a red blood-corpuscle, and have a round, 
large, deeply staining nucleus, surrounded by a narrow rim of non- 
granular protoplasm. These are known as lymphocytes. 2. Large 
mononuclear leucocytes several times as large as the foregoing. They 
have a round or oval nucleus, with a relatively larger amount of non- 
granulated protoplasm. 3. Transitional forms, which resemble the last 
named, except that the nuclei are indented or S-shaped. 4. Poly- 
nuclear leucocytes. These are usually about the size of the foregoing 
variety, but they may be somewhat smaller. The nuclei are long and 
irregular and stain deeply. The protoplasm contains granules that 
stain by a combination of both basic and acid dyes, but by neither 
alone. The cells are therefore called " neutrophiles." 5. Leucocytes 
similar to the last form, except that their protoplasm contains highly 
refractive granules that are stained by acid dyes alone. For this 
reason they are usually called " eosinophiles. ,, The proportion of each 
variety in the normal blood is fairly constant ; lymphocytes, 15 to 25 
per cent. ; polynuclear, 65 to 80 per cent. ; mononuclear and transi- 
tional forms, 6 per cent. ; and eosinophils, 2 per cent, or less. (See 
Plate IX.) 

Physical Appearance. For the purpose of examination of the blood 
a drop or two is quite sufficient. In olden times much stress was laid 
upon the physical character of the blood drawn in bulk. The signifi- 
cance of the " buffy coat " was dwelt upon by all clinicians, not alone 
because of its value from a therapeutic stand-point, but also because it 
was held to indicate the type of the disease that was present. At pres- 
ent, however, we rely very little upon the results of the naked-eye 
examination. By this examination we may be able to distinguish 
bright-red arterial blood from darker venous blood, and also when 
arterial blood has become deficient in oxygen from any of the causes 
of veuous engorgement and cyanosis. In chlorosis and hydremias the 
blood is pale, as though mixed with water, while in severe leukaemias 
it has a slight milky tinge. On the other hand, in carbonic-oxide 
poisoning the blood becomes of a brighter red, while in poisoning with 
chlorate of potash and aniline, and in grave cases of poisoning with 
nitrobenzol and hydrocyanic acid, it is brownish-red or chocolate- 
colored. 

For accuracy in diagnosis reliance must be placed upon instruments 
of precision. These are the microscope, the hamioglobinometer, the 
hsemocytometer. By this examination we determine (1) the size and 



372 GENERAL DIAGNOSIS. 

shape of the red cells ; (2) the morphological characteristics of the 
white cells ; (3) the number of the reel cells ; (4) the number of the 
white cells ; (5) the presence of new elements as nucleated red cells 
and myelocytes ; (6) the presence of parasites ; (7) and the amount of 
haemoglobin. 

Method. A drop of blood for this examination may be taken from 
the lobe of the ear or the finger-tip. The surface should be thoroughly 
cleansed with alcohol, and dried carefully. If the finger is used, it 
should not be unduly constricted. The puncture should be made 
forcibly and quickly, in order that the drop of blood may ooze freely. 
If it is difficult to secure the blood, it is well to allow the first or 
second drop to escape before any is collected. When the flow is started 
and the finger cleansed the succeeding drops are gathered on cover- 
slips. If the lobe of the ear is selected, it should be steadied with the 
fingers of the left hand, which at the same time stretches the skin. It 
may be necessary to puncture to the depth of one-eighth of an inch, or 
even more if the skin is bloodless. The puncture should be made on 
the lower surface or edge of the lobe. A surgical needle, a small lancet, 
or the bayonet-pointed instrument devised for the purpose, should be 
used. The nib of a new steel pen, one-half of which has been broken 
off, answers fully as well. 

It is well to remember the precaution insisted upon by all who ex- 
amine the blood frequently, to beware of " bleeders. " It sometimes 
becomes a very serious matter when hemorrhage is started in a patient 
who is the subject of haemophilia. 

Mode of Examination. As soon as the blood flows freely, without 
pressure, the apex of a drop may be touched by the cover-glass, which 
has been previously prepared. The cover-glass should not touch the 
skin, and as soon as it is covered by the blood it should be placed face 
downward upon the slide, or if cover-slip preparations are to be made, 
upon a corresponding cover-glass. The precaution must be taken to 
have the slide and cover thoroughly cleansed. It is well to keep them 
in alcohol or in a weak acid solution after they have been previously 
cleansed with soap and water, and when removed from the alcohol 
solution they should be thoroughly polished with a clean handkerchief. 
The blood will then spread evenly over the surface with the slightest 
pressure upon the cover-glass. If the slide and cover are warmed 
slightly before using, it will not be necessary to use the pressure just 
referred to. 

Blood collected in this way may be examined fresh or be put aside 
for staining and future examination. 

Examination of Fresh Blood. By the examination of fresh 
blood we learn of the presence of parasites and of the occurrence of 
rouleaux formation. In a general way we can learn the number of 
red and white cells respectively, the degree of coloring of the red cells, 
the shape and size of the red cells, and the presence of blood-plates. 
An unusual increase in leucocytes may be detected, and the diagnosis 
of leukaemia made without further investigation. 

Cover-slip preparation*. For the purpose of future study, and 
particularly in order to determine the differential count of the white 



THE BLOOD. 



373 



corpuscles, cover-slip preparations are made. The covers are cleansed 
and the blood secured in the manner previously described. The cover- 
glass, which has been touched to the summit of the drop, is let fall 
upon another somewhat diagonally. (See Fig. 100.) The drop 



Fig. 99. 



Fig. 100. 





Proper method of holding a cover-gla: 



Illustrating the position of cover- 
glass during the spreading of hlood 
films (Cabot.) 



spreads over the adjoining surfaces of the cover-glass. As soon as the 
spreading ceases, slide the glasses off, but do not lift them apart. Dr. 
Manson introduced the use of tissue paper drawn over a slide, with 
the object of getting a more uniform thickness of film. Pakes uses 
this method applied to cover-glasses, which should be not less than 1J 
inch by f inch. The cover-glasses are held in a clip and smeared by 
means of cigarette paper cut into strips across the direction of the rib. 
The cover-slip should be dried in a gas or alcohol flame at once, by 
means of which the preparation is fixed. 

" Fixation" may also be done by alcohol and ether, or by corrosive 
sublimate solution. The cover-glass should be immersed for one-half 
hour in equal parts of alcohol and ether. After such fixation malarial 
organisms and nucleated red corpuscles are more readily found. 

Fixation with formol is quickly secured. Dilute one part of formol 
with nine times its volume of water ; dilute one part of this mixture 
with nine times its value of alcohol. The resulting fluid will fix im- 
mersed specimens in one minute. 

Fixation of heat is best when the white cells are to be studied. By 
this method it is best to put the cover-slips in a dry-heat sterilizer at 
a temperature of 110° or 115°. If this cannot be done, place the 
cover-slips on the end of a copper plate at least a foot long, the other 
end of which is heated by a Bunsen burner or a gas flame. The cover- 
slips should be placed on the plate at that point on which water boils 
when dropped upon the surface of the copper. They should be placed 
face downward and kept there from fifteen to twenty minutes. When 
they cool they are ready for staining. 

Staining. The greatest care should be taken to have a perfectly 
clean, dry cover-glass, which should be handled with forceps, to avoid 
moisture and soiling. (1) The prepared cover-glass, arranged as above, 
should then be immersed for a few minutes in a solution of eosin : 



374 GENERAL DIAGNOSIS. 

Eosin 0.5 

Alcohol (70 per cent.) ■ . 100.0 

This solution should be diluted one-half before using. (2) The 
cover-glass should then be dried and stained for three or four minutes 
in a saturated aqueous solution of methylene blue, also diluted one-half 
before using (Chunzinsky-Plehn's mixture). Or, instead of the latter, 
stain for half an hour to several hours in Delafield's hematoxylin. This 
hematoxylin -stain is made in the following manner : To 400 c.c. of a 
saturated solution of ammonia alum add 4 grammes of hsematoxylin- 
crystals dissolved in 25 c.c. of strong alcohol. Leave this exposed to 
the light and air in an unstoppered bottle for three or four days. 
Filter and add 100 c.c. of glycerin and 100 c.c. of methylic alcohol. 
Allow the solution to stand until the color is sufficiently dark. Then 
filter and keep in a tightly stoppered bottle. The stain should ripen 
for at least two months before using. For blood-work the solution 
is used in its full strength. By this double stain, a modification of 
EhrlieNs hcematoxylin-eosin mixture, the red corpuscles are stained red, 
the nuclei blue, the bodies of the leucocytes light lilac and their nuclei 
darker, the eosinophile granules a brilliant red. 

Ehrlich' s Tri-aeid Stain. The Ehrlich tri-staining mixture is the 
best that can be selected for staining. Thayer says the following is a 
satisfactory modification of Ehrlich's formula : 

Saturated aqueous solution of acid fuchsin . . 2 

Water 3 

Saturated aqueous solution of orange-G. . . 6.25 

Saturated aqueous solution of methyl-green . . 6 

To be added, drop by drop, while shaking the solution : 

Water . . .15 

Alcohol 10 

Glycerin . . . . . . . 5 

The stain is spread over the cover-glass specimen with a glass rod, 
and in from one to five minutes washed off with water. If the cover 
glass has not been heated very long it will not be necessary to keep 
the stain long in contact with the blood, although specimens which are 
heated an hour require at least five minutes for the stain to take. 
After the specimen is stained and washed in water it should be dried 
between layers of filter paper and mounted in balsam. It can then be 
examined at leisure with the twelfth oil-immersion with diaphragm 
open. 

Specimens heated for one or two hours stain better than those which 
have been treated only a short time. The red cells appear orange or 
buff, the nuclei of the colorless corpuscles green or greenish-blue, the 
neutrophilic granules a violet or lilac color, the eosinophilic granules a 
deep red. The nuclei of nucleated red corpuscles, when present, are 
stained an intense deep green, almost black. 1 

Another method much used and urged by Hewes is as follows : 
The blood, after fixation, is subjected for four minutes to the modified 
Ehrlich stain, which is made as follows : 

1 Thayer, loc. cit. 



THE BLOOD. 375 

Ehrlich-Biondi-Heidenhain three-color mixture . . 1.7 grammes. 

Acidfuchsin 0.05 " 

Absolute alcohol . . . . . . . 2 c.c. 

Distilled water . 18 c.c. 

After immersion wash the specimen in water and then subject it 
from one-half to ten seconds to Loffier's solution of methylene-blue. 
Again wash the specimen, dry, and mount in balsam. 

Loffler's solution is saturated alcoholic solution of methylene-blue, 
30 c.c. ; potassic hydrate (1 : 10,000 solution), 100 c.c. 

The Red Corpuscles or Erythrocytes. In thickly spread blood 
the cells are arranged in the form of rouleaux. If such rouleaux are 
absent in a preparation thus poorly spread it is an indication of great 
reduction in the red cells. 

In thinly spread films the red cells are recognized by their color and 
shape. They vary from 6 to 9// in diameter. The lighter colored 
centre, due to the biconcavity of the corpuscle, sometimes causes con- 
fusion. It must be remembered, too, that the corpuscles readily become 
crenated, an appearance which may be confounded with pigmentation 
or other abnormal change. In them, too, a slight molecular movement 
is sometimes seen, which must not be confounded with the amoeboid 
movements in dying cells or with the rapid motion of malarial pigment. 

Poikilocytosis. The variations in size and shape are indications 
of disease. In forms of anaemia the red cells may be larger than nor- 
mal ; they may be irregular in shape, or they may be smaller than 
normal. Large cells are known as maerocytes, small cells as microeytes. 
Cells that are irregular in shape are known as poikilocytes. They may 
be oval, pointed, angular, or reniform. 

Achromia. When the red cells are stained the haemoglobin takes 
the orange-G. of the tri-colored mixture of Thayer, causing the red 
cells to be brilliant yellow or pale orange in tint. An idea of the 
amount of haemoglobin can thus be obtained. When the haemoglobin 
is diminished the centre is pallid, although in extreme poverty of 
haemoglobin the colored rim may be a faint outline only (achromic 
forms). 

Nucleated Red Corpuscles or Blasts. They contain one or 
more nuclei. The stroma takes the golden acid stain and the nucleus 
the pure basic stain. They are divided in accordance with their size, 
and the depth of the color of the nuclei, into three varieties : 

(1) The normoblast. It is the size of a normal red blood-corpuscle. 
The stroma is golden in color ; the one or more nuclei are deeply 
bluish-black, homogeneous. The nucleus occupies one-fourth to three- 
fourths of the whole corpuscle. It is deeper in color than the nuclei 
of the white blood-corpuscle. It is the parent cell of the red blood- 
corpuscle. 

(2) The megaloblast. They are larger than a red blood-corpuscle. 
The color of the stroma is less intense than that of the normoblast, and 
the nucleus is blue rather than black, and not compact and homoge- 
neous. The nucleus is more compact and more clearly defined than the 
nucleus of a white blood-corpuscle. It is found on the marrow of the 
embryo. / 



376 



GENERAL DIAGNOSIS. 



(3) The microblast. They are smaller than the normal. There is 
but little stroma, and the nucleus is deep black 

Blasts are found in anaemia. An excess of normoblasts indicates 
very active regeneration of blood. 

Polychromatophiles. These are red blood-corpuscles in which 
the stroma takes not only the normal acid staining elements but also 
the blue basic or purple neutral stain. They are degenerate forms of 
red blood-corpuscles. 

Degenerate Forms. The coloring matter is irregularly distrib- 
uted and the stroma appears disintegrated. 

When thus stained we can readily find nucleated red cells, but the 
fibrin or blood-plates, as a rule, are destroyed. 

Counting the Corpuscles. It is of the greatest clinical impor- 
tance to be able to estimate the number of red cells in a given quantity 
of blood, in order that approximately at least we may know of its 
globular richness. For this purpose hsemocytometers are used. 

The hsemocytometers, or blood-counters, most frequently used in 
this country are those of Gowers and Thoma-Zeiss. 

Gowers 7 instrument (Fig. 101) consists (1) of a small pipette, A, 
which, when filled, holds exactly 995 cubic millimetres ; it is for meas- 

FlG. 101. 




Hreuiocytometer of Gowers. 



uring the diluting fluid ; (2) a capillary tube, B, graduated for 5 cubic 
millimetres ; (3) a small glass jar, d, in which the dilution is made ; (4) 
a small glass stirrer, E, for mixing the blood and diluting fluid in the 
jar ; (5) a small lancet, F ; (6) a brass stage-plate, c, carrying a glass 
slip on which is a cell one-fifth of a millimetre deep. The bottom of 
the cell is divided into one-tenth millimetre squares. On the top of 
the cell rests the cover-glass, which is kept in place by the pressure of 



THE BLOOD. 



377 



two springs proceeding from the ends of the stage-plate. 995 cubic 
millimetres of the diluting fluid are measured and blown into the 
mixing-jar ; then 5 cubic millimetres of blood are added and the two 
thoroughly mixed. A small drop of the mixture is then placed upon 
the cell, the cover-glass gently adjusted and held in place by the two 
springs. From five to ten minutes should be allowed to elapse, so 
that the corpuscles will have time to settle to the bottom of the cell. 
The stage-plate is then placed under a microscope, and the number of 
red blood-cells in ten squares counted. This number multiplied by 
10,000 gives the number in a cubic centimetre of pure blood. It is 
better to count a large number of squares, take the average, and multi- 
ply by 100,000. This number is the product of the dilution (200) by 
the square surface of the cells, 100 (10 X 10), and again by 5, the 
depth of the cell : 200 X 100 X 5 = 100,000. To facilitate seeing the 
fine lines marking the squares, a soft black lead-pencil should be 
gently rubbed over them before the drop of diluted blood is placed on 
the cell. Counting of the white cells is made much easier if the 
diluting fluid is colored a pale violet with a very small quantity of 
gentian-violet. The white cells then appear a distinct blue, while the 
red cells are unaltered. As diluting fluids, a 1 per cent, solution of 
common salt, or a 2J per cent, solution of bichromate of potash, as 
recommended by Daland, may be employed ; or Toison's fluid can be 
used. 

Toison's Fluid. It is made up as follows : Distilled water, 160 c.c. ; 
glycerin, 30 c.c. ; sulphate of soda, 8 c.c. ; chloride of soda, 1 gramme ; 
methyl-violet, .025 gramme. 

Another hsemocytometer is the Thoma-Zeiss (Fig. 102). It is pre- 
ferred by most clinicians. It consists of a heavy glass slip (a), in the 



Fig. 102. 





0.100 mm. 
too mm. 







\o\ 





Thoma-Zeiss blood-counting apparatus. 



middle of which is a cell (B) exactly j-q millimetre in depth. The cell 
is lhnited at the periphery by a circular gutter to prevent fluid placed 
upon the cell from flowing beyond it between the slip and cover-glass. 
The floor of the cell is ruled into squares whose sides are ^ mm. 
Double lines mark out large squares, each containing sixteen small 



378 



GENERAL DIAGNOSIS. 



squares. Thick, carefully ground cover-glasses (D) are provided in 
the case. The ordinary Potain melangeur (8) is used to measure and 
mix the blood. It consists of a capillary tube, the upper portion of 
which is blown into a chamber {E) holding 100 c.mm. The stem of 
the tube is graduated at 0.5 and at 1 c.mm. 

To use the instrument, a drop of blood is obtained from the finger or 
lobe of the ear, the point of the capillary tube is inserted into the drop, 
and blood sucked up to the mark 1 c.mm. The point of the tube is 
then quickly wiped free from excess of blood and inserted into the 
diluting fluid, which is drawn up to the level of the mark 101. The 
proportion of blood and diluting fluid is then 1 to 100 c.mm. The 
blood and diluting fluid are now thoroughly mixed. The diluting fluid 
in the stem of the melangeur is now blown out and a drop of the 
blood-mixture placed on the cell. The cover-glass is adjusted carefully 
to avoid bubbles and to prevent the escape of the fluid between it and 
the slip. The cover-glass is now pressed firmly down until Newton's 
color-rings appear, and then the slip is allowed to stand for five or ten 
minutes, until the corpuscles have settled to the bottom of the cell. 

The cell is ruled into 400 small squares, groups of sixteen squares 
being separated by double lines. The surface of a square is ^oS" square 

millimetre, and the depth of the cell be- 
ing y^ millimetre, the space overlying 
each square is ^oVo" °^ a CUD ic millimetre. 











Fig. 


103 










::} 




••" 


;> 


»*.' 


f'" 




.■ 


'A' 


--- 


-'''■' 


°, • 


°o" ° 




J c « 


'e 






."a' 


O I " 










o°o 


,.-.: 




} 




° o' O 


8 o°o 


O O 0°0 


c°« 


. : 


c 


/ 




° »"« 


8 o 


%' C 


\ 


.• 


of". 


' 


>5 


- 


.V 


>": 


; \ 


°o o 




;" 


o ° o 






;' 


v 


1 ° ° 


f." 


v; 


•: 


;' 


: a « o 






°- 


o 0, 


'= V 


r ^ n 


v i 


»« 


„° 


' o • 




'• 




. ■"„ 


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J 'J'b 


°<,v 


,° 






: '■ 


0° 


%r o " o 


•V: 


',' 


IV. 






>\\ 



Appearance of blood in the Thoma- 
Zeiss cells. 



In estimating the number of cor|^uscles in 
a cubic millimetre of blood, multiply the 
number of corpuscles counted in all the 
squares by 4000 and the product by the 
dilution, which is 1 to 100 or 1 to 200, 
according as 1 or 0.5 c.mm. of blood has 
been used. The last product is now to be 
divided by the number of squares which 
have been included in the count, the quo- 
tient being the number of corpuscles in a 
cubic millimetre of blood. The results 
are accurate in proportion to the care 
exercised in the measurement of the blood and diluting fluid, and espe- 
cially in proportion to the number of squares counted. 

In the estimation of ivhite blood-cells the pipette made by Zeiss is 
employed. In this instrument the blood is diluted ten times by a 
solution of one part of a J per cent, acetic acid solution to ten parts of 
distilled water. By means of this solution red cells are dissolved and 
the nuclei of the white cells are rendered distinct and easy of recogni- 
tion. Toison's fluid, mentioned above, may also be used. The ordi- 
nary Thoma-Zeiss slide is employed, and the average number of white 
cells in each small square is multiplied by 40,000. To obtain accurate 
results four entire fields should be counted. 

The hcematokrit is an instrument devised for the estimation of the 
percentage- volume of red corpuscles by means of centrifugal force. In 
Dalaud's article will be found a full description of the instrument, and 
from the same article the following method of using it is abstracted : 



THE BLOOD. 379 

" The finger or ear and apparatus are prepared as above. An incision 
is made deep enough to produce a good-sized drop of blood. This is 
drawn into a hsematokrit tube by means of suction through an attached 
rubber tube, one finger being placed over the free end when the rubber 
tube is removed, to prevent the loss of blood. The filled tube is then 
placed in the frame of the hsematokrit and a second prepared exactly 
as the first. The larger wheel is then rapidly rotated for two minutes 
at seventy-seven turns of the handle-crank per minute (giving alto- 
gether 20,000 rotations of the frame), and the result read from the 
scale multiplied by 2 gives the percentage-volume. It has been found 
by experimenting that each division upon the scale of the haematokrit 
tube represents 100,000 corpuscles." This procedure is not available 
for the determination of the volume of leucocytes unless the number 
exceeds 20,000, at and above which number an approximate estimate 
may be readily determined. A distinct white band appearing between 
the red cells and the clear fluid, having the width of one line, may 
be considered as representing from 15,000 to 20,000 leucocytes. 

Number. The normal number of red cells — as stated previously — 
is approximately 5,000,000 per cubic millimetre. They may be 
reduced to 500,000. A reduction below 3,000,000 indicates grave 
anaemia. When the reduction is less than 1,500,000 the anaemia is said 
to be pernicious or malignant. It must be remembered that temporarily 
the red cells are reduced during menstruation and lactation. At 
puberty there is also a reduction. On the other hand, when the blood 
is concentrated by profuse sweating or exhaustive diarrhoea, the num- 
ber of red cells is increased, while they are lowered Avhen the blood is 
diluted by large draughts of fluid or by subcutaneous injections of fluid. 
A cold bath may temporarily concentrate the peripheral blood, and 
thereby increase the number of cells. Red cells are always lessened in 
the aged, and are reduced in number after great exertion. They are 
increased in number after fasting, and diminished after a meal, particu- 
larly if much fluid is taken. 

Oligocythemia. Oligocythemia is the name applied to a dimi- 
nution in the number of red blood-cells, from whatever cause. It is 
usually associated with oligochromcemia (deficiency of haemoglobin), 
which, however, in idiopathic anaemia is absolute, not relative. Marked 
oligocythemia can be detected with the microscope alone, and can be 
estimated accuratelv with the haemocytometer or haematokrit. (See 
Fig. 102.) 

The White Corpuscles. The white or colorless corpuscles are 
recognized by their absence of color, by their irregular shape and their 
size, which is larger than that of the red, and by the amoeboid move- 
ments which they undergo, particularly if placed on a warm stage. 
They number from 8000 to 10,000 per cubic millimetre. They are 
readily recognized by the peculiar affinity which they have for various 
aniline dyes. They appear as granular nucleated cells in stained 
specimens. The method of staining has been described, and the vari- 
eties of leucocytes found in normal blood indicated on page 371. In 
addition to determining the number by counting, as described in the 
paragraph which gives the method of counting the red cells, a so-called 



380 GENERAL DIAGNOSIS. 

differential count is made. This count enables us to determine the 
proportion of the many varieties of leucocytes. 

In counting the white blood-corpuscles, Phear advises the use of the 
camera lucida. The most convenient form is the Zeiss- Abbe drawing 
camera, used with the stage of the microscope in a horizontal position. 
The image of the field is projected on a piece of paper or card- 
board lying horizontally on the table immediately to the right of the 
microscope stand. The ruled squares on the floor of the hsemocytom- 
eter cell are accurately marked out on the cardboard. The image of the 
corpuscles which lie on the unruled part of the cell floor is thrown 
by means of the camera on the cardboard, and the corpuscles which 
appear to lie over each square are enumerated and included in the 
count. It is convenient to use a mechanical stage. It is essential 
that the eye-piece, objective, and tube-length used during the count 
should be the same as on the occasion of marking out the squares on 
the cardboard. For the dilution of the blood, that recommended 
by Sherrington, 1 consisting of distilled water, 300 cubic centimetres ; 
sodium chloride, 1.2 grammes ; neutral potassium oxalate, 1.2 grammes, 
and methylene-blue, 0.1 gramme, is excellent. The blood-corpuscles 
are not stained, but their shape and color are preserved. The nuclei of 
the white corpuscles are in every instance stained, facilitating the dis- 
tinction of the white from the red corpuscles. For the differential 
count of the white corpuscles it is desirable to work with an immer- 
sion lens. 

Differential Counting. After the specimen is carefully stained with 
the triple solution it is ready for differential counting of the white cells, 
as well as determining the presence of nucleated red cells. To make 
the differential count a large number of leucocytes should be studied. 
The best plan to pursue is to begin at the upper left-hand corner of the 
blood film and count across the film to the right-hand corner. Then 
move the slide so that an adjacent field comes into view, when the pro- 
cess is to be repeated. In this manner the entire field is covered. In 
ordinary leucocytosis a thousand leucocytes can be seen in a seven- 
eighth inch cover-glass specimen. We may find an abnormal variety 
of leucocytes ; an abnormal proportion of some one of the normal 
leucocytes ; an abnormal number of all the leucocytes. 

Fluid Preparations. Dr. A. G. Phear lays stress on the advan- 
tages of fluid preparations over the cover-slip method. In the cover- 
slip method leucocytes are inevitably flattened and distorted in the 
process of making and fixing the film ; some are washed away during 
the staining ; others obscured by the red corpuscles. In the fluid 
preparation the white cells are fixed and preserved as approximately 
spherical bodies ; camera lucida drawings and measurements of them 
could be relied on as accurate. A solution of methylene-blue (0.2 per 
cent.) in 40 per cent, alcohol is used for diluting the blood. The red 
corpuscles are laked so that the white cells alone remain conspicuous. 
" A small quantity of the diluting solution is added to a drop of blood 
on a glass slide and the two are thoroughly mixed by directing a cur- 

1 Proceedings of the Royal Society, vol. lv. 



THE BLOOD. 381 

rent of air through a pipette on to the surface of the fluid. The fluid 
is allowed to spread as a thin film under a cover-glass and the edges 
then sealed with vaseline." The contour of the normal polymorpho- 
nuclear cells is rounded. Their diameter vary from 9 to 10//. The 
complex nucleus can be made out by changing the focus, the nucleus 
being, in fact, " an undivided elongated body, in places deeply con- 
stricted, elsewhere bulged into rounded lobes." The lymphocytes and 
the large hyaline cells represent the extremes of cells, differing in the 
amount of protoplasm around the nucleus ; all grades are readily 
found. The nuclear diameter is fairly constant in these cells, varying 
only between 4.5 and 5.5//. Large oval cells, as much as 14// in 
length, with the nucleus large and irregular, usually reniform, are 
seen. The protoplasm becomes rapidly and uniformly stained an 
opaque blue color with methylene-blue. The coarsely granular or 
eosinophile cells (diameter from 9.5 to 10.5//) are at once recognized 
in the film prepared with methylene-blue solution, notwii hstanding 
the absence of an acid dye ; the large refractile granules are tinged 
with a greenish color. The cells containing basophile granules (diam- 
eter about 8//) have a characteristic appearance. The protoplasm con- 
tains granules of medium size, many of which are aggregated in one 
or more deeply stained clumps near the surface of the cell. The non- 
granular part of the protoplasm is stained a peculiar mauve or purple 
color. The nucleus is usually massed at the centre of the cell, and 
stains a slate or grayish-blue color. 

Separate counts over different areas of one preparation gave uniform 
results, showing that the blood was evenly mingled with the diluting 
fluid. Not less than 500 cells should be enumerated at a time ; the 
more the better. It was desirable to use a mechanical stage and to 
work with an immersion lens. The blood should always be procured, 
if possible, before the first meal of the day is taken, since this is the 
time at which the influence of meals is least likely to be evident. 

Leucocytosis. Leucocytosis is a temporary increase in the number 
of white blood-cells of the same morphological varieties as in health, 
with an excess of the polynuclear forms (neutrophile leucocytosis). 
Such increase may be physiological or pathological, as indicated in the 
following : 

Physiological Leucocytosis. (1) Pregnancy (14,000 and up- 
ward) ; (2) during digestion (from 1000 to 7000 above normal ; more 
in children) ; (3) new-born (12,000). 

Pathological Leucocytosis. An excess of leucocytes occurs in 
the following diseases : (1) Leukaemia ; (2) pernicious ansemia ; (3) 
chlorosis ; (4) diseases of lymphatic glands ; (5) disease accompanied 
by exudations, as pleurisy, pericarditis, meningitis, polyarthritis, and 
especially croupous pneumonia ; (6) inflammatory condition associated 
with exudation, as appendicitis, pyonephrosis, perinephritic abscess, 
tonsillar and retropharyngeal abscess, acute pancreatitis, cholangitis ; 
(7) many acute infectious diseases, as varicella, variola, vaccinia, epi- 
demic cerebrospinal meningitis ; cholera, typhus fever, trichinosis, glan- 
ders, diphtheria, scarlet fever, erysipelas, pyaemia and septicaemia, 
rheumatism, abscesses, and gangrenous inflammation ; (8) after hemor- 



382 GENERAL DIAGNOSIS. 

rhage and (9) just before death, leucocytosis of agony. On the other 
hand, leucocytosis is not found in uncomplicated cases of (1) influenza 
(Boston Medical and Surgical Journal, March 22, 1894) ; (2) uncom- 
plicated cases of typhoid fever ; (3) tuberculosis when not associated 
with cavity-formation or hyperplasia of lymphatic glands (Stein and 
Erbman, Deutsch. Archiv. f. klin. Med., Bd. 56) ; (4) many forms of 
carcinoma and sarcoma, gastric ulcer and benign pyloric stenosis 
(Schreuger, Zeitschr. f. klin. Med., 1895, 27, 475), although it may be 
present in gastric carcinoma. 

Letjcopenia. Diminution of the number of leucocytes is seen (1) 
in starvation, as in cancer of the oesophagus • (2) the latter weeks of 
typhoid fever ; (3) leukaemia complicated by infection. 

Diagnostic Value. The value in diagnosis of determining the 
presence of leucocytosis is great. Its absence excludes the first series 
of cases ; its presence the last. If leucocytosis is present in the course 
of, or convalescence from, typhoid fever, it points to a complication, as 
thrombosis. A post-febrile rise, due to a complication, may be distin- 
guished from a true relapse by an increase of the white cells. 

It is best determined with a haemocytometer. Dry preparations, 
according to Ehrlich's method, are necessary for a study of the various 
forms of leucocytes. (See under Leucocythaemia, page 396, and 
Plate X.) 

Increase of Special Leucocytes. Lymphocytosis. A relative 
increase in the lymphocytes , with or without a total increase of leuco- 
cytes, is seen in infants, and is a common accompaniment to rickets 
and hereditary syphilis. In some forms of scurvy it is also found. 
In adults lymphocytosis occurs in chlorosis and pernicious anaemia and 
in secondary anaemia of syphilis and typhoid fever. It occurs in haemo- 
philia, in adenitis, and splenic tumors. Cabot states that it is also 
found at the end of scarlet fever and measles, in pneumonia with de- 
layed resolution, and in some forms of phthisis. The larger forms of 
leucocytes are seen. Absolute lymphocytosis occurs in lymphatic 
leukaemia. 

Eosinophilia. An increase in the percentage of eosinophiles, with 
or without leucocytosis, is seen in many affections of the bones, in affec- 
tions of the skin, and in diseases of the genital apparatus in females. 
It is also seen in certain disturbances of the sympathetic nervous 
system, as in cyanosis and vasomotor troubles associated with menstru- 
ation and pregnancy. The bone diseases in which the eosinophiles are 
increased are osteomalacia, sarcoma, carcinoma, and in those affections 
of the bone and marrow with which pernicious anaemia and splenic 
myelogenous leukaemia are seen. The skin diseases are urticaria, 
pellagra, herpetiform, dermatitis, and pemphigus, in herpes, eczema and 
prurigo, psoriasis, lupus, and myxoedema. In the eruption of scarlet 
fever and syphilis they are increased, but not in measles or smallpox. 
In various affections of the uterus and ovary, in functional disorders 
connected with the same, the eosinophiles are increased. They are 
also increased in gonorrhoea and prostatitis. They are increased in 
those infections in which Neusser's granules are found. Thayer, in 
Osier's clinic, has found marked increase in the eosinophiles in trichi- 



PLATE X. 



FIG. 1. 






Blood from Case of Secondary Anaemia. 

i. Poikilocytes. 3 and 6. Lymphocytes. 

2. Macrocytes. 4. Nucleated red blood-corpuscle. 

5. Polynuclear leucocytes. 
(Oc. 4, ob. T ^ immersion.) Drawn by J. D. Z. Chase. 



FIG. 2. 



* 










p° f& 



s*.>o 




Leukaemic Blood. 

1. Polynuclear leucocytes. 3. Large mononuclear leucocyte. 

2. Eosinophile cell (mononuclear). 4. Small lymphocyte. 

(Oc. 4, ob. T V immersion.) Drawn by J. D. Z. Chase. 



THE BLOOD. 383 

nosis — in fact, recognizing this condition by the differential count. 
Diminution in the eosinophils takes place during digestion, and in 
most of the infectious disorders accompanied by leukocytosis, and in 
typhoid fever and diphtheria. Malignant disease with hemorrhage 
which causes leucocytosis is, however, associated with diminution of 
the eosinophiles. Neusser has indicated the following diagnostic points 
of value in eosinophilia. They are given by Cabot as follows : 

1. In the diagnosis between puerperal mania and puerperal sepsis, 
eosinophilia points to the former. 

2. Between a tumor connected with the genital system and one not 
so connected, eosinophilia points to the former. 

3. In determining whether a given case of hysteria, neurosis, or 
psychosis is likely to be benefited by castration, the presence of eosino- 
philia favors the operation. 

4. In malignant disease an eosinophilia points to a metastasis in the 
osseous system (tumors of the spleen are not included in this rule). 

5. In cases of doubtful syphilis, eosinophilia combined with lympho- 
cytosis (see above) speaks in favor of syphilis. 

6. The diagnosis of any obscure form of " uric-acid diathesis" is 
helped by finding an increase of eosinophiles. 

7. In distinguishing malignant liver disease from other liver disease, 
eosinophilia points to the latter. 

Pathologic Leucocytes. Myelocytes. The occurrence of myelo- 
cytes in the blood is pathological. Their well-known occurrence in 
myelogenous leukaemia and pernicious anaemia need not be referred to. 
They have been found, however, in a number of infections, but usually 
only when there is present a grave form of anaemia. Their occurrence 
is not of great diagnostic value. They are non-amoeboid. They are 
large mononuclear neutrophiles or eosinophiles, with large, well- 
defined, lateral, spherical nuclei. Occasionally they are small when 
they are recognized by the granules and the very pale large nucleus. 
The " mast-zellen "■ are mononuclear, coarsely granular basophiles. The 
nucleus is fragmented or three-lobed. 

Neusser's Granules. When making a differential count we also 
study certain granules in the leucocytes. Neusser has described peri- 
nuclear basophilic granulations in the leucocytes, which are demon- 
strated by staining the blood with the following modification of Ehr- 
lich's triple stain : 

Saturated aqueous solution of acid fuchsin . . . 50 c.c. 

Saturated aqueous solution of orange-G. . . . 70 " 

Saturated aqueous solution of methyl green . . 80 " 

Aquae dest. . . . . . . . . . 150 " 

Abs. alcohol 80" 

Glycerin 20 " 

The granules in question occur as separate bodies or as groups, lying 
in the protoplasm immediately around the nucleus. They are met 
with in the mononuclear forms in particular, and, according to Neusser, 
are composed of some derivative of the nucleo-albumin and indicative 
of increased uric-acid formation. The granules occur in gout, and also 
in certain cases of myelogenous leukaemia, tuberculosis, diabetes, and 



384 



GENERAL DIAGNOSIS. 



other diseases. They are significant of a nric acid diathesis " in the 
clinical sense." In discussing Neusser's paper, Lonit called attention 
to the fact that similar granules occur in the leucocytes of the bone- 
marrow of rabbits. 

Other observers have found these granules in a variety of conditions, 
and incline to regard them of less significance than Neusser is disposed 
to admit. 

The Haemoglobin. An estimation of haemoglobin is made, in order 
to determine the richness of red cells in this substance. For this pur- 
pose a hsenioglobinometer is used. 

H^emoglobhstometers. Growers' hsemoglobinometer (Fig. 104) con- 
sists of (1) a closed tube, D, containing coloring-matter representing 
the color human blood should have normally if diluted one hundred 
times ; (2) a corresponding empty tube, C, graduated in an ascending 
scale from 10 to 120 ; (3) a capillary glass tube, b, marked at 20 cubic 
millimetres ; a small guarded lancet, F, and a small bottle with a pipette 
stopper, A, for distilled water. A few drops of distilled water are 
first placed in the empty tube, c, to prevent the coagulation of the 
blood, which would occur if the blood were first put in the tube. The 
finger or lobe of the ear, previously cleansed with water and ether, is 
then deeply stabbed with the lancet, so that the blood will flow freely, 
care being taken to avoid squeezing the punctured part ; 20 cubic milli- 
metres of blood are then quickly drawn up in the capillary tube and 



Fig. 104. 






Gowers' hsemoglobinometer. 



at once blown into the graduated tube, which is shaken, to allow the 
blood to become diffused in the water. The tubes containing the stand- 
ard coloring-matter and the diluted blood are now held up, side by 
side, against a sheet of paper, and more distilled water added, drop by 
drop, with repeated shakings, until the colors in the two tubes match. 
The height to which the column of diluted blood and water has risen 



THE BLOOD. 385 

in the graduated tube represents the percentage of haemoglobin con- 
tained in the blood tested. 

Fleischl's haemometer consists of a. small metal table with an aper- 
ture in the middle, under which is a reflector made of plaster-of-Paris. 
The opening is occupied by a small well having a glass bottom and 
divided into two equal compartments. The standard color of the blood 
at different dilutions is represented by a wedge of glass, colored with 
Cassius purple, which is, of course, pale in color at the extreme edge 
and deepens in intensity with its thickness. This wedge of glass is 
moved under the table by a rack and pinion, and is accompanied by 
a graduated scale. One-half of the well receives simply the light from 
the plaster-of-Paris reflector, while the other rests upon the ruby glass 
and obtains light through it. The light from a candle, gas-jet, or oil-lamp 
must be used. A small pipette and several capillary tubes about f 
inch in length, and mounted on slender metal handles, are employed to 
obtain the necessary amount of blood ; each one of them will hold 
enough normal blood to produce, when properly diluted, a color corre- 
sponding to that of the ruby glass at the 100 mark. For use, one end 
of a capillary tube is carefully lowered upon a drop of blood, which 
immediately fills it ; the tube is then at once washed in one of the 
compartments of the well, which contains some water. The compart- 
ments are now equally filled with water, and the well so placed that 
the side containing blood receives yellow light, as from a candle, 
while the other receives light through the wedge of glass. The glass 
is now moved by the rack and pinion until the intensity of the color 
in the two compartments is the same, and the percentage is then read 
off through the small opening behind the well. 

Both Gowers' and Fleischl's instruments are about equally accurate, 
and both are graduated for a higher percentage of haemoglobin than is 
the average with Americans, which may be as low as 96 per cent. 

Color-index. The haemoglobin usually increases or diminishes 
with increase and diminution of the red cells. If there is any variation 
from this percentage the determination of this variation is known as 
the color-index. In a healthy individual with 5,000,000 red cells per 
cm. the normal percentage of haemoglobin should be 100. We then 
say the color-index = 1. If the haemoglobin is diminished, the color- 
index is less than 1. The color-index is estimated, first, by reducing 
the count of the cells to a percentage ; second, by dividing this percent- 
age into the haemoglobin percentage. Thus if the normal percentage 
of red cells is present — that is 100 — and the haemoglobin is reduced to 
50 per cent., the color-index is y 5 ^, or 0.5 ; a reduction of the red cells 
to 2,500,000 cells = 50 per cent, of the normal. INow, if the haemo- 
globin is 40 per cent., the color-index will be f $, or 0.8. 

Diminution in the amount of haemoglobin is seen in anaemia, and 
usually the reduction is lower than the reduction of the red cells. In 
chlorosis the reduction in haemoglobin is very great, and in consequence 
the color-index is lower than in secondary anaemias. The average 
haemoglobin per cent, in a large number of chlorotic cases, studied by 
Cabot and by Thayer was about 42 per cent. At the same time in 
most of these cases the number of red corpuscles was over 4,000,000. 

25 



386 GENERAL DIAGNOSIS. 

Melanaemia. Melanaeinia is a rare condition, in which black, 
brown, or yellow granules are seen floating, either free among the 
blood-cells, or, more commonly., enclosed in cells resembling leuco- 
cytes. They are present in malarial fevers, particularly the chronic 
forms, and in relapsing fever. 

Lipaemia is the presence in the blood of fat, usually in the form of 
small droplets, easily detected by the microscope. The diagnosis can 
be confirmed by treating the fresh preparation with a 1 per cent, solu- 
tion of osmic acid, followed by a weak aqueous solution of eosin. The 
fat-drops will appear black among the faintly stained acid corpuscles. 
A saturated solution of Soudan three in 96 per cent, alcohol will stain 
fat drops bright red or orange. Lipsemia occurs in chronic alcoholism, 
chronic nephritis, and diabetes, and after-injuries to the bone-marrow. 

The Acidity of Blood. The total acidity of the blood is best 
determined by Landois' titration-method, as follows : Prepare a deci- 
normal solution of tartaric acid by dissolving 7.5 grammes of the 
chemically pure salt in 1 litre of distilled water. By diluting centi- 
normal and millinormal solutions are obtained. Prepare a series of 
solutions as follows : 

I. contains 0.9 c.c. centinormal solution tartaric acid ~f 0.1 c.c. satu- 
rated potassium sulphate solution. 

II. contains 0.8 c.c. centinormal solution tartaric acid -f- 0.2 c.c. sul- 
phate solution. 

IX. contains 0.1 centinormal acid + 0.9 c.c. sulphate solution. 

X. contains 0.9 c.c. millinormal acid -J- 0.1 c.c. sulphate solution. 

XVIII. contains 0.1 c.c. millinormal acid -j- 0.9 c.c. sulphate solution. 

In each of a series of watch-glasses mix 1 c.c. fluid (each watch- 
glass containing a different strength, as in the series above given) with 
0.1 c.c. of blood. This can be done by a graduated pipette. The 
pipette of a Thoma-Zeiss hsemocytometer answers very well. 

Test the contents of each watch-glass with a strip of delicate litmus- 
paper, and note in which solution the reaction is neutral. This opera- 
tion must be done quickly, the whole process not taking more than one 
and a half minutes (V. Jaksch). 

Suppose 0.4 c.c. tartaric acid neutralizes 1 c.c. of blood ; now, 0.4 
c.c. tartaric acid neutralizes 0.0016 gramme caustic soda. Therefore 
0.1 c.c. blood — 0.0016 sodic hydrate and 1 c.c. = 0.16. The normal 
alkalinity is 1 part XaOH to 26 to 30 parts of blood, or 1 c.c. blood 
= 0.33 to 0.38 gramme XaOH. 

The alkalinity of the blood is diminished in : 

1. Fevers and cachexias. 

2. Toxic conditions, as uraemia, diabetes, and jaundice. Or certain 
poisons, as C0 2 and phosphorus. 

3. Pernicious anaemia, simple anaemia, and leukaemia. 

4. Chronic articular rheumatism and gout (not in acute articular 
rheumatism). This may, perhaps, be due to the accompanying anaemia. 

It is increased, perhaps, in chlorosis, though this is doubted by some 
authorities. 

Uric Acid. GarrooVs test. By this test we can determine the pres- 
ence or absence of large amounts of uric acid in the blood. A few c.c. 



THE BLOOD. 387 

of blood-serum or of serous fluid are placed in a watch-crystal ; add to 
this 6 to 10 drops of a 30 per cent, solution of acetic acid. Immerse a 
thread of linen in the fluid, and keep it at a low temperature for from 
twelve to twenty-four hours. If uric acid is present in large amounts 
at the end of twenty-four hours, crystals collect upon the thread. Their 
true nature is determined by the microscope (see Urine) and the murex- 
ide test. The serum may be secured by a blister. 

The Specific Gravity. The specific gravity of the blood is best 
determined by the following method : 

Prepare a series of solutions of water and glycerin in such proportions 
that they form a series gradually ascending in specific gravity from 
1040 to 1080. Place from 80 to 100 c.c. of each solution in a series 
of small glass jars and bring a drop of blood exactly in the middle of 
each, as follows : A hypodermic syringe is connected by a small 
rubber tube with a right-angled glass capillary tube. A drop of blood 
is obtained from the finger in the usual manner, and is drawn by means 
of the syringe into the capillary tube. By a gentle motion of the 
syringe a small drop is expelled into the fluid from the point of the 
tube. The drop will remain stationary if the specific gravity of the 
fluid equals that of the blood ; it will sink if the fluid be of less specific 
gravity than that of the blood, or will rise if the fluid be of greater 
specific gravity than the blood. By repeated examination the specific 
gravity of any specimen can be easily determined. The glycerin mix- 
ture can be preserved by the addition of a small amount of thymol, 
and may be used a second time ; but in this case it is necessary to rede- 
termine its specific gravity before each usage. By the specific gravity 
one can estimate the amount of haemoglobin because the former runs 
parallel to the percentage of the latter. Two methods are employed — 
the water and glycerin method and the method of Hammerschlag. 

Hammerschlag's method is as follows : Mix in a urinometer glass 
such quantities of chloroform and benzol that the specific gravity is 
about 1059. Take a drop of blood from the punctured ear by a medi- 
cine dropper or a capillary tube, and blow it into the chloroform-benzol 
mixture. The blood does not mix but floats like a red bead. Add 
chloroform, drop by drop, if the blood sinks to the bottom. Add 
benzol if it rises to the top. After each addition stir the mixture with 
a glass rod. When the drop remains stationary in the body of the 
fluid its specific gravity is the same as that of the fluid as a whole. 
Take the specific gravity and you have the specific gravity of the blood. 
Air should not be blown into the fluid with the blood drop. The fol- 
lowing table gives the relations of the specific gravity to the haemo- 
globin, from which an estimate of the haemoglobin can be made : 



Specific gravity. 


Haemoglobin. 


1033 to 


1035 . 


. 25 


to 


30 per cent 


1035 " 


1038 . 


30 


a 


35 


1038 " 


1040 . 


35 


iC 


40 


1040 " 


1045 . 


. 40 


11 


45 


1045 " 


1048 . 


. 45 


il 


55 


1048 " 


1050 . 


. 55 


u 


65 


1050 " 


1053 . 


65 


(C 


70 


1053 " 


1055 . 


70 


li 


75 


1055 ' ' 


1057 . 


75 


Li 


85 


1057 " 


1060 . 


85 


(I 


95 



388 



GENERAL DIAGNOSIS. 



The specific gravity of the blood is normally less in women, and is 
diminished in severe symptomatic anaemias, pernicious anaemia, chlo- 
rosis, leukaemia, and, according to Monti (Archiv. f. Kinderheilk., Bd. 
xviii. S. 161), in nephritis. It is increased in infancy and acute febrile 
diseases, as pneumonia, pleurisy, etc. (Monti, ibid.), and also in diph- 
theria (Fibrenthal and Bernhard, ibid., Bd. xvii. H. 5 u. 6). 

Coagulation Time. An estimate of the time required for the blood 
to clot is valuable, particularly in prognosis. In case of jaundice, for 
instance, in which blood destruction is going on rapidly, it is well to 
know the clotting power of the blood, as surgical interference should be 
resorted to in obstructive forms whenever the coagulation time is very 
rapid. The method devised by Wright is the best at our command. 

Parasites in the Blood. 

The principal vegetable parasites are those associated with the infec- 
tions and described in Chapters XIX and XX. They are (1) spirilla 
of relapsing fever ; (2) tubercle-bacilli ; (3) anthrax-bacilli ; (4) bacilli 
of glanders ; (5) typhoid bacilli ; (6) streptococci and staphylococci ; 
(7) the bacilli of yellow fever. 

The animal parasites are : (1) Filaria sanguinis hominis ; (2) dis- 
toma haematobium ; (3) plasmodium of malaria. 

Fig. 105. 



-i .: : „ ^:- 



y^> 



Filaria alive in the blood. Instantaneous photomicrograph. Four hundred diameters 
magnification. Four millimetres Zeiss apochromatic. (F. P. Henby.) 

The Filaria Sanguinis Hominis. Filariae are found hi the blood 
and lymph of persons who live in the tropics, and in a few instances 
have been found in native Americans (John Guiteras). They have a 
blunt, rounded head with a tongue-like process and a long, pointed tail. 

They produce lymphatic swellings (particularly of the scrotum), 
chyluria, and haematuria. 

Patrick Manson 1 says the following are the commonest mistakes in 
the search for filariae : (1) The use of too high a magnify ing-power ; 
(2) employing too strong illumination ; (3) searching unmethodically 
and in too small a quantity of blood ; (4) looking for filariae in blood 
drawn from the body at a time when the particular species sought for 
is normally absent from the circulation. He describes three forms : 
Filaria sanguinis hominis noctuma (the ordinary form) ; filaria san- 
guinis hominis diurna ; and perstans. The last appears to be the one 



Trans. Seventh International Congress of Hygiene and Dermography, vol. i. p. 93. 



THE BLOOD. 389 

associated with the production of the disease known on the west coast 
of Africa as " sleeping sickness." He prefers dry preparations of the 
blood, stained with a J per cent, eosin solution or a weak solution of 
fuchsin (one drop of the saturated alcoholic solution to an ounce of 
water). If a thin film of blood, before it has fully dried, be held over 
acetic acid so as to imbibe the fumes, and be then stained in a \ per 
cent, solution of eosin, the blood is stained, but any filar iae remain 
pearly white. 

The filariae may have been discovered accidentally, or are sought for 
because of hcemato-chyluria, or lymph-scrotum, elephantiasis, or varicose 
groin glands (" Demerara groin"). In the former the chyluria is inter- 
mittent. Microscopically, the urine contains molecular fat-globules or 
granules and a few red corpuscles. 

ANEMIA. 

Anaemia is a condition characterized by a reduction in the number 
of red blood-cells, or of their haemoglobin, or of the albumin, or of all 
combined. 

The most casual observation may be sufficient for the recognition of 
anaemia. The color of the surface, the appearance of the mucous mem- 
branes, and the evident breathlessness of the patient are indications of 
diminution in the amount of blood, or of some of its constituents, as the 
red cells, or of the coloring matter of these cells. On inquiry it would 
be found that the patient is easily prostrated, that there is breathless- 
ness on exertion (aggravated on ascending any height), that there is 
palpitation and perhaps cardiac oppression. The patient will com- 
plain of neuralgias in various parts of the body, and especially of the 
neuralgia so often seen in the inframammary region of the left side. 
(See Pain.) Headache will be a more or less constant symptom, and 
of this peculiarity, that it is increased when the patient goes up stairs, 
and is often throbbing or pulsating. The anaemic subject has usually 
a poor appetite and suffers from gastralgia, although it must be re- 
membered that the gastric symptoms of anaemia are as often primary 
as secondary. Many of the train of symptoms which attend neuras- 
thenia occur in the course of anaemia. 

On physical examination of the patient the appearances as above 
indicated are found, although grave anaemias may be present, and yet 
the lips are bright red, the color under the nails fair, and the cheeks 
flushed, especially if the examination is made in the evening. Refer- 
ence must be made to the chapter on the Color or Hue of the Surface 
for a description of the appearances of anaemia. 

A study of the heart and bloodvessels usually yields the physical 
signs that attend anaemia. The vascular phenomena are described in 
the section on Diseases of the Heart. Here, again, it must be remem- 
bered that considerable anaemia may be present without any murmurs 
in the bloodvessels. 

The Blood. The final diagnosis rests upon an examination of the 
blood. Sometimes the most apparently anaemic subjects yield normal 
results in blood examination, while the most plethoric in appearance 



390 



GENERAL DIAGNOSIS. 



may be very anaemic. The various forms of anaemia give rise to blood 
changes in a measure peculiar to the respective variety. The primary 
anaemias, or haemolytic varieties, to which pernicious anaemia and chlo- 
rosis belong, have characteristics which will be described in the special 
sections. 

In anaemia from hemorrhage the red corpuscles may be reduced to 
1,500,000. The haemoglobin is reduced to a degree greater than that 
of the red cells. The leucocytes are increased in number, the polynu- 
clear forms being relatively much less than the other varieties. 

The red corpuscles are paler than normal ; their white centres are 
increased in size. This is known as achromia. There is some poikilo- 
cytosis. An excess of nucleated red corpuscles, or blasts, are seen in 
grave anaemias. If the normoblasts are in excess, active regeneration 
is in progress ; if the megaloblasts, there is reversion to embryonal regen- 
eration, a serious import in an anaemia. A megaloblast anaemia is 
associated with general increase in size of red cells and an increase of 
the macrocytes. In fatal anaemia, as in purpura, the red cells are like 
those in the form just described, although nucleated red corpuscles 
are absent. The white cells are also reduced, although the mono- 
nuclear forms are numerous. 

In the oligocythaemic forms of anaemia, other than the hemorrhagic, 
the occurrence of poikilocytosis is constant and marked. Nucleated 
red corpuscles are not common, but large nucleated cells in which 
karyokinetic figures occur. These corpuscles have pale staining 
nuclei. Achromic forms, polychromatophiles, and degenerate forms 
are seen. There is usually moderate leucocytosis. 

For clinical purposes it is necessary to make a number of divisions 
of anaemia, though on etiological and pathological grounds many of 
them will no doubt soon be grouped together. 

The following classification of anaemias is helpful in the study of 
anaemia. In it both pernicious anaemia and chlorosis are regarded as 
haemolytic in origin, the destructive agent probably being absorbed 
from the intestine. 



I Non-cytogenic, 



Anaemia, 



Cytogenic, 



Hemolytic, 



Oligocythemic, 



Leucocytic, 



^ Non-leucocytic, 



Pernicious anaemia. 

Other toxic anaemias. 

Chlorosis. 

Parasitic anaemia (some forms). 

f Parasitic ansemia (some forms). 
J Post-hemorrhagic ansemia. 
I Anaemia from loss of albumin. 
I Anaemia of malnutrition. 

r Spleno-myelogenic. 
Leucocythaemia, < Lymphatic. 

I Medullary or myelogenic. 

Hodgkin's disease (?). 



I. Toxic Anaemias. The poison may be developed in the body or 
introduced from without. Toxaemia is, sometimes at least, a factor in 
the anaemias which develop in the course of acute infectious diseases or 
during convalescence from them. According to Hunter, pernicious 
anaemia should be classed under this head. The metallic poisons, par- 



THE BLOOD. 391 

ticularly lead, mercury, arsenic, phosphorus, the potassium salts, espe- 
cially the chlorate ; certain of the antipyretics, notably pyrodin ; and 
the aniline-preparations are capable of producing anaemia. 

II. Parasitic Anaemias. Anaemia may be parasitic 1. To this 
class belongs the anaemia of malaria, which is believed to be due to 
the plasmodium malarice described by Laveran. 

2. Certain intestinal worms are found associated with marked anaemias. 
(a) The bothriocephalus latus sometimes produces a disease closely re- 
sembling pernicious anaemia, but whether by direct destruction of the 
blood, or by the development of toxic products, themselves destructive, 
is uncertain ; it may be present in large numbers without giving rise 
to anaemia. 

Fig. 106. 




Severe anaemia (Reproduced from colored plate.) Dry preparation, x 300. Great poikilocytosis. 
Many macrocytes and microcytes. To the left above, a mononuclear leucocyte. 

(b) The ankylostomum duodenale is believed to be the cause of the 
anaemia known variously as Egyptian or African chlorosis, tropical 
anaemia, brick-burner's anaemia, etc. 

, ._ (c) The anguillula intestinalis is the cause of " Cochin-China diar- 
rhoea " and its associated anaemia. 

3. The filaria sanguinis hominis may produce anaemia by blocking 
up the lymph-channels. 

4. The Bilharzia hcematobia may produce anaemia by inducing haema- 
turia. 

III. Anaemia from Hemorrhage. Anaemia may be due to hemor- 
rhage. In addition to accidental and post-partum causes, purpura, 
haemophilia, menorrhagia, and metrorrhagia are frequent causes. 

IV. Anaemia from Constitutional and Local Diseases. Anaemia 
is often a marked symptom of constitutional and local diseases, such as 
tuberculosis, syphilis, cancer, rheumatism, scrofula, scurvy, rickets, 
Bright' s disease, chronic catarrhal gastritis, and others. The anaemia 
here may be due to the malnutrition and interference with digestion 



392 



GENERAL DIAGNOSIS. 



brought about by the disease, or, as in the case of Bright's disease, 
in part to the direct loss of albumin, and in dyspeptic conditions to 
inability to take and assimilate food. 

In many cases of simple symptomatic anaemia the spleen may become 
progressively enlarged, probably secondarily. In other cases there is 
an enlargement of the spleen in Hodgkin's disease. In no case is 
there a primary splenic anaemia. 

V. Anaemia of Malnutrition. Anaemia may also be the result of 
malnutrition from deficient or improper food, or from the poisonous 
influences of unsanitary surroundings. 

Chlorosis. 

Chlorosis, or chloro-anaemia, is a form of anaemia occurring especially 
in young girls about the period of puberty, and characterized by great 
pallor of the skin and mucous membranes, with a greenish tint of the 
skin, a pearly eye, languor, weariness, suppression or irregularity of 

Fig. 107. 





DATE 


X 


X X« 


\ y 


\y 
y™ 


\y 


2/ / 

y^ 


*Xi 


2/ / 

y is 


zy' 


3/ 

y 1 


?> y 
y* 


yw 


/if. 


/ 


































HO'/ 
































105 
































100 


5,000,000 






























95 
































90 




























f * 




85 


























+*' 






80 


4,000,000 






















p* 








75 






















4 










70 


















,<•■- 


■"■*■»- 


--*>' 










65 
















p* 
















60 


3,000,000 






























55 
















/ 
















50 














* 


















45 








/ 




% 


^> 


















40 


2,000,000 






/ 




V 




















35 








' 
























30 






/ 


























25 




4, 


.J* 


























20 


1,000,000 


•* 






























14,000 








y\ 
























12,000 






j. 


S 


\ 






,• 


— •. 


^„, 


,s* 


N, 








10,000 






y 




\ 




f 












'"*"*% 






8,000 


• — 


r-*>' 






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Chlorosis. Straight lines, number of red cells; small dots, percent, of haemoglobin ; large dots, 

number of white cells. 



menstruation, venous hum in the vessels, dyspnoea, palpitation, dizziness, 
neuralgias, and an unstable condition of the nervous system. In spite 
of the extreme pallor there is usually but little loss of flesh. The skin 



PLATE XI 



FTG. 1. 



O (D 

o Xg So* 3$ 

o,° o 

Blood from Case of Chlorosis, showing slight Staining of the Red 
Blood-eorpuscles, and presence of Mononuclear Leucocytes. 

(Oc. 4, oli. T V immersion.) Drawn by J. ]). Z. Chase. 



FTG. 2. 



j n 



Q 
O' J 



° o 

O o 

© oO 

• - 00 g 



Blood in Pernicious Anaemia, showing Maeroeytes 
and Mieroeytes. 

( Eos in slain, oc. 4. "I). ,'._, oil immersion.) Drawn by J. 1). Z. Chase. 



THE BLOOD. 393 

may be pigmented, especially around joints. The bowels are usually 
constipated ; the urine abundant, pale, and of low specific gravity. 
The digestion is disturbed, the appetite capricious, and the patients 
sometimes crave unwholesome things, such as earth, slate-pencils, 
vinegar, and the like. Hyperacidity of gastric juice is commonly 
present. A systolic murmur over the base of the heart is common. 
Gastralgia is more common than in other forms of anaemia. 

The changes in the blood are very important. There is always a 
marked reduction in the haemoglobin, the percentage falling sometimes 
to 30 or 25 per cent, of the normal. The red blood-cells are usually 
also reduced, but not in the same proportion as the haemoglobin. For 
example, there may be 4,000,000 red cells, but only 30 per cent, of 
haemoglobin. Sometimes there is no diminution in the number of red 
cells ; the latter, however, appear pale (achromia), vary considerably in 
size, microcytes and occasionally poikilocytes are present, and, hi severe 
cases, nucleated red corpuscles are found ; occasionally macrocytes 
occur, but in general the size of the red cells is below that which is 
usually found. The number of leucocytes varies but little from the 
normal, but there may be a slight increase. Occasionally there is a 
rise of temperature, but it is probably due to some complication. 
(See Plate XL, Fig. 1.) 

The cause of chlorosis has not been determined satisfactorily. Vir- 
chow has established the existence of congenital narrowing of the blood- 
vessels. Sir Andrew Clark thinks it is due to the absorption of 
poisonous matter from the intestine ; the great benefit that follows 
saline purgatives in many cases indicates that faecal toxaemia is a factor 
in these cases. Forchheimer 1 also looks upon it as intestinal in origin. 

Sex and puberty are predisposing causes ; but chlorosis may occur 
in boys, and appear in girls before puberty, and in young women con- 
siderably after that period. The prognosis is favorable ; it may, how- 
ever, be complicated with gastric ulcer, chorea, tuberculosis, and endo- 
carditis. Recovery is often slow and interrupted by relapses. 

Pernicious Anaemia. 

Pernicious or idiopathic anaemia is a form in which the diminution 
of red blood-cells reaches an extreme degree. It occurs without ade- 
quate known cause, and runs a progressive course with remissions ; it 
usually terminates in death. 

The disease usually develops slowly and insidiously, the patient pre- 
senting the ordinary symptoms of anaemia — pallor, weakness, shortness 
of breath, palpitation, venous murmurs, loss of appetite, and impaired 
digestion. As the disease progresses the skin becomes of a pale lemon 
hue, weakness and dyspnoea increase, the patient has attacks of dizzi- 
ness, faintness, and ringing in the ears ; there may be slight oedema, 
and hemorrhages from the nose, the bowels, and into the retina occur. 
The hemorrhages are small and distinct in the skin and mucous mem- 
branes. The urine is of low specific gravity, and usually contains an 
increased amount of uric acid. According to Hunter, the urine should 

1 Trans. Assoc. Amer. Phys., 1893. 



394 



GENERAL DIAGNOSIS. 



be dark and contain a pathological amount of urobilin, some renal 
epithelium, a few casts containing blood-pigment, and an increased 
amount of iron. The bowels may be disturbed by diarrhoea. 

A peculiarity of the disease is the occurrence of fever of an irregular 
type. The temperature rarely rises higher than 102° or 103° in the 
evenings, and is followed by a morning remission. It is not usually 
present in the early stages of disease, may be absent for weeks at a 
time when the disease is fully developed, and may cease entirely in the 
later stages. 1 

In spite of extreme exhaustion, ansemia, and wide-spread functional 
disturbance, there is no emaciation ; the patient appears well nourished. 

The blood appears pale and watery to the naked eye ; there is diffi- 
culty in obtaining by puncture a sufficiently large drop for examina- 
tion. The specific gravity is lowered, often being 1028 instead of 
1055. It has been found deficient in fibrin, iron, and nitrogen. 

The blood-changes in idiopathic anaemia are characteristic, and are 
essential to the diagnosis of the disease. In brief they are : (1) Very 
great reduction in the number of red blood-cells ; (2) an absolute dimi- 

FlG. 108. 



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Pernicious anaemia. Straight lines, number of red cells ; small dots, per cent, of haemoglobin ; 
large dots, number of white cells. 

nution in the amount of haemoglobin, but as compared with the number 
of red cells there may be a proportionate increase ; (3) considerable 






1 See "Idiopathic Anaemia: A Report of Three Cases." Mnsser, Phila. Co. Med. 
Soc. Trans., 1885. 



THE BLOOD. 395 

variation in the size of the cells, the average size of the cells probably 
being larger ; (4) poikilocytosis ; (5) nucleated red blood-cells ; (6) 
degenerative cells. (See Plate XI., Fig. 2.) 

Reduction in the number of red blood-cells (oligocythemia) reaches 
a more extreme degree in pernicious ansemia than in any other disease ; 
the number often falls below 1,000,000, and in one case reported by 
Quincke 1 the number was only 143,000 per cubic millimetre. The 
shape of many of the cells is altered ; they are oval, elongated, bent, 
or have projections of their substance (poikilocytosis). The size of the 
cells varies ; there are microcytes and megaloblasts ; but the occur- 
rence of a distinct proportion of large nucleated red blood-cells (megal- 
oblasts) is regarded by Ehrlich as almost diagnostic. The average 
size of the red cell seems to be increased, and so is the proportionate 
amount of haemoglobin in each cell. The latter is a very character- 
istic symptom (the only one, according to Hunter). There are also 
red corpuscles which are stained by methylene-blue ; these are regarded 
as degenerative by Ehrlich. The leucocytes are {t usually diminished 
in number, showing a relative increase in the small mononuclear ele- 
ments (lymphocytes, small transparent forms), while the multinuclear 
elements are relatively diminished, sometimes being under 50 per 
cent." 2 

The blood condition is not constant, but is subject to wide varia- 
tions. Von Xoorden has recently found that in a very short time a 
change in the form of the blood, a ' ' formal " crisis, may occur. A 
"formal" overflow of the blood with poly nuclear leucocytes and 
nucleated red blood-cells takes place before a period of improvement. 
Whereas, before a period in which the blood becomes worse and before 
the final stage, the blood becomes poor in leucocytes and nucleated red 
blood-cells. 3 

Secondary sclerotic changes in the spinal cord cause late symptoms 
of locomotor ataxia. 

The etiology of the disease has not been determined satisfactorily. 
It is more common in Germany and Switzerland than in other parts 
of Europe or in America. It occurs most frequently after the twen- 
tieth year, and between that and the age of fifty. Excluding the 
influence of pregnancy and parturition, sex makes no difference. Pre- 
vious exhausting disease, chronic gastric and intestinal catarrh, great 
physical over-exertion, exposure, great shock or fright, precede in 
certain cases the development of the disease. It is probably due to 
faulty hsematogenesis and haemolysis. 

Petrone and Halst regard the disease as infectious and its germ 
identical with that found by Frankenhauser. Von Jaksch supposes 
that it is brought about by a living contagium. Hunter traces the 
cause to a poison produced by bacteria in the gastro-intestinal canal. 

Diagnosis. The most important diagnostic features of the disease 
are extreme oligocythemia, relatively high percentage of haemoglobin 
(color-index high), great poikilocytosis, which may, however, occur in 

1 Deut Arch, fur klin. Med., Bd. xx. 

2 W. S. Thayer: Boston Med. and Surg. Journ., February 16 and 23, 1893. 

3 Quoted by Weiss, Diagnostisches Lexikon. 



396 GENERAL DIAGNOSIS. 

any severe anaemia, a noticeable number of large nucleated red blood- 
cells (gigantoblasts), an average increase in the size of the cells, and 
all this without emaciation or discoverable local disease which can bear 
a causative relation to the anaemia. In addition, retinal, subcutaneous, 
and submucous hemorrhages, a urine with high specific gravity, high 
color, with urobilin in excess, alternating with urine of low specific 
gravity, in the absence of organic disease, point to pernicious or idio- 
pathic anaemia. 

Leucocythsemia. 

Leucocythaemia, or leukaemia, is a disease of the blood-making organs, 
characterized by great and persistent increase in the white blood-cor- 
puscles ; by a diminished number of red blood-cells, which are altered 
in shape and size, and display nucleated and degenerate forms ; by a 
lessened amount of haemoglobin, and by changes in the spleen, lym- 
phatic glands, or medulla of bone. It is a persistent and progressive 
cellular proliferation. It resembles a tumor of solid tissue in its cel- 
lular overgrowth. The disease occurs twice as frequently in men as in 
women, and two-thirds of the cases appear between the twentieth and 
fiftieth years. In women, pregnancy, parturition, and the cessation of 
menstruation are causative factors, while in both sexes depressing influ- 
ences upon body or mind and antecedent disease, particularly malarial 
fever, have a distinct influence. 

The first symptom noted is generally enlargement of the abdomen ; 
subsequently the patient complains of pains in the splenic region, weak- 
ness, dyspnoea, hemorrhage, oedema, and digestive derangements. Occa- 
sionally profuse hemorrhage from trifling cause, as the drawing of a 
tooth, has been the earliest symptom noted. The increase of white 
cells and diminution of red cells is progressive, and soon makes itself 
evident in the pallor of the skin and mucous membranes, and in 
increasing weakness and dyspnoea. Pallor is not a constant symptom 
of leukaemia. A high grade of color is consistent with advanced 
leukaemia. 

In the so-called spleno-meduUary form of the disease the spleen 
steadily enlarges, but may attain considerable size before the patient 
becomes aware of it. The enlargement is not usually painful, but gives 
rise to a feeling of distention, weight, and dragging. There may be 
tenderness on palpation and pressure, and sometimes the patient com- 
plains of sharp, stabbing pains, due either to attacks of local peritonitis 
or to sudden enlargement of the spleen and consequent stretching of 
the capsule. The splenic enlargement is uniform, so that its shape and 
characteristic notch are unchanged. Moreover, the spleen remains in 
contact with the abdominal walls, lying in front of the splenic flexure 
of the colon, pushing aside the descending colon and small intestine, 
moving with respiration, and presenting the usual physical signs of a 
solid organ. Not infrequently the enlargement is so great as to fill 
the left hypochondriac and iliac regions, and reach beyond the middle 
line toward the right groin. Sometimes a venous hum can be heard 
over it. Pallor, however, is not a constant symptom ; more frequently 
the cheeks are flushed and the lips red. 



PLATE XII. 



FIG. t. 



% 









\ 









c 



0S 






• 



«; \ 









#1 



!> 6 



i. Globiferous cell. 
3. Polynuclear cell. 



Lymph-gland, Retroperitoneal Region. 

Hardened in Alcohol ; Rosin's Stain. X 1500. 

2. Globiferous cell containing polynuclear and eosinophile cells. 

4. Mononuclear cell. 5. Globiferous cell. 6. Eosinophile cell. 



FIG. 2. 



s40MSSMm± 




iSfe' 



1. Lymphocyte. 

^. Polynuclear leucocyte 



Blood — Leukaemia. 

Hematoxylin and Eosin. 

2. Kosinophile cell (mononuclear). 

4. I. arg-e mononuclear leucocyte (myelocyte' 



THE BLOOD. 397 

As the result of this enlargement the diaphragm is pushed upward, 
increasing the dyspnoea already caused by anaemia, and sometimes in- 
ducing palpitation. The gastric functions are disturbed from press- 
ure ; vomiting and other symptoms of dyspepsia are common. 

A rise in temperature is a very common symptom. The fever is of 
irregular type, usually with nocturnal exacerbations, the temperature 
not often rising above 102°. The febrile type may be intermittent or 
remittent, and sometimes there are periods of apyrexia. 

The pyrexia is said to be most marked toward the close of the 
disease. Gowers states that the cases in which there is most fever 
are usually those of rapid course, considerable dropsy, and extensive 
hemorrhage. 

As the disease progresses weakness increases ; anaemia becomes more 
intense ; oedema, ascites, or hydrothorax occurs ; hemorrhages from the 
nose, gums, bowels, stomach, lungs, or uterus further exhaust the patient ; 
digestion is poor and diarrhoea is common. 

Headache and tinnitus are frequent symptoms, occasionally delirium 
and coma may occur, and deafness is not uncommon toward the close 
of the disease. The eyes may be the seat of leuksernic retinitis. 

The liver is enlarged, often to a considerable degree, but without 
special symptoms. The same is true of the lymphatic glands and other 
adenoid tissue. (See Plate XII., Fig. 1.) The marrow of the bones 
becomes the seat of disease in some cases, but it does not usually give 
rise to symptoms during life ; certain bones, however, may be tender. 1 

The Blood. The most characteristic and important changes from 
a diagnostic point of view occur in the blood. The blood when drawn 
from the finger is strikingly pale and whitish, an appearance supposed 
at one time by Bennett to be due to admixture of pus. It coagulates 
slowly, is of lower specific gravity than normal, and its alkalinity is 
diminished. When placed under the microscope it is at once seen 
that the number of white cells is greatly increased. If a drop of 
blood is mixed with some distilled water containing a small quantity 
of gentian-violet, the white cells are stained a decided blue and can be 
picked out with the greatest ease. Instead of there being one white 
cell to 300 or 500 red, the ratio falls as low as 1 : 5 or 1 : 3, or even 
lower. Authorities differ as to the degree of increase necessary to dis- 
tinguish leucocythsemia from leucocytosis, some including all in which 
the ration is 1 : 50 or lower, and others excluding those in which the 
ratio is greater than 1 : 20 or 1 : 12. In leucocytosis the increase 
takes place solely in the polynuclear neutrophilic leucocytes. 

Not only the white cells greatly increase in number, but they vary 
considerably in size and react differently to staining-fluids. 

Ehrlich has described five varieties of leucocytes. The pathologi- 
cal changes in the normal leucocytes in this disease are : (1) The small 
mononuclear elements are relatively diminished ; (2) the great differ- 
ence in size of the multinuclear elements ; (3) the presence of myelo- 
cytic elements, in which the protoplasm is filled with fine neutrophilic 

1 See "A Case of Leucocythsemia." Musser and Sailer, Amer. Journ. of the Med. 
Sciences, 1896. 



398 



GENERAL DIAGNOSIS. 



granules ; (4) the presence of a normal proportion of eosinophils in so 
extensive an increase of leucocytes. 1 (Plate XII., Fig. 2.) (5) Large 
mononuclear elements with karyokinetic figures (Miiller). (6) Mast- 
cells. Satisfactory study of these can be obtained only by cover-glass 
preparations. 



Fig. 109. 





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Leukaemia. Straight line, red cells ; small dots, haemoglobin ; large dots, white cells. 

The essential points in the diagnosis of leucocythaemia are : 1. Such 
an excess of leucocytes in the blood that the ratio of white to red falls 
below 1 : 50 or 1 : 20 ; if the ratio is higher, the white cells should 
show a progressive increase. The individual leucocytes vary in size 
and characteristics, as already described. 2. Enlargement of the spleen 
or lymphatic glands. 3. The occurrence of hemorrhages and dropsies 
unexplainable by disease of the heart, kidneys, or other organs. 4. 
The symptoms of anaemia of a high grade, as dyspnoea. 5. Leuksemic 
retinitis. 6. Anaemic fever. 7. The presence of the myelocyte of 
Ehrlich, " mast-cells/' and nucleated red blood-cells. 8. Specific 
gravity below 1040. 9. Excess of uric acid in the urine. 



1 W. S. Thayer, loc. cit. 



THE BLOOD. 399 

The lymphatic form of the disease is rare. It is characterized by 
enlargement of the lymphatic glands and by the great increase in the 
proportion of the lymphocytes. The total increase in the colorless 
elements is not so excessive. Eosinophils and nucleated red cells 
are rare. The myelocyte of Ehrlich is not present. A case of a purely 
myelogenous form has never been authenticated. Combination-forms 
may also occur. It must be remembered that the number of myelo- 
cytes is no indication of the involvement of the bone-marrow. 

In secondary or so-called splenic ancemia we find the same enlarge- 
ment and the general symptoms, though hemorrhage is not so common. 
Leucocythaemia is distinguished from it by the great excess of leuco- 
cytes and by their special characteristics. 

In lymphadenoma, or Hodgkin's disease, there is extreme anaemia, 
though the excess of leucocytes found in leucocythaemia is seldom 
reached, and the cells are smaller. The glandular enlargement of 
lymphadenoma is an early and constant symptom, the spleen not being 
much enlarged. The cervical glands are the ones usually first in- 
volved. 

The duration of leucocythaemia is usually two or three years ; but 
some cases terminate in six months or less, and some last six or seven 
years. The size of the spleen and the degree of oligocythemia appear 
to have no influence. Gowers states that the cases in which enlarge- 
ment of the lymphatic glands is an early symptom run a course appar- 
ently much more acute than others, but he admits that the number of 
such cases is comparatively small. 

Death results most frequently from gradual loss of strength. Hem- 
orrhage from various organs and surfaces is the immediate cause in 
many cases. It- occurs in about three-fourths of the cases, and, when 
not directly fatal, increases the pre-existing asthenia. Diarrhoea and 
pulmonary complications are not infrequent causes of death. 

Acute Leukcemia. Cases have been described, especially in children, 
in which there is a diminution of red cells of haemoglobin. Nucleated 
red cells are present as well as an excess of white blood-corpuscles, 
which consist almost entirely of large mononuclear elements, without 
granulation. There is usually fever, and the disease runs a course 
much resembling an infectious one. The lesions are leucocytic infil- 
tration of the various organs. 1 

1 See "Acute Leukaemia." Fussell, Jopson, and Taylor, Assoc. Am. Phys., vol. x. 
1898 ; and Musser, Trans. Phil. Co. Med. Soc, 1887. 



CHAPTER XXIII. 

THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 

Knowledge of symptoms of morbid processes essential ; they control conclusions drawn 
from data. — Morbid processes are few. I. Alterations in blood and circulation: 
Anaemia and plethora — Hyperemia, active and passive— CEdema and dropsy 
— Thrombosis and embolism — Hemorrhage — Blood-pressure. II. Disturbances 
of nutrition: Inflammation — Gangrene and necrosis — Fever — Atrophy and 
hypertrophy. Degenerations : Albuminous — Fatty — Colloid — Mucous — Pig- 
mentary — Calcareous — Amyloid— Fibroid. III. Anomalies of growth: Tumors 
— Cysts — Cancer. 

Although we may have secured all the data obtainable by inquiry 
and by observation, and, if possible, made a diagnosis based upon them, 
it frequently happens that the conclusion arrived at is not final and per- 
haps cannot be, from the nature of the case. We are prompted, there- 
fore, to view the case from a different stand-point, to utilize our 
knowledge of the phenomena of morbid processes, and, for the purpose 
of comparison, to review the features of such as apparently resemble 
the process under consideration. Thus, for instance, in an obscure 
case of fever, the objective and subjective phenomena have been fully 
inquired into —we are unable to decide whether the disease under con- 
sideration is a septic process with obscure lesion, a form of miliary 
tuberculosis, or of malignant endocarditis. The known symptoms of 
each are considered (our knowledge of such symptoms depending upon 
our knowledge of the phenomena of the respective morbid process) and 
compared with the symptoms presented by the case in question. In 
this manner a diagnosis by exclusion is made. Moreover, after a diag- 
nosis is made, a review of the symptomatology of morbid processes 
serves as a check upon the conclusions that have been reached. We 
should also, after making a diagnosis, compare the symptoms of the 
process as exhibited in the patient with the symptoms which we know 
to be common in the suspected disease. 

It is necessary, therefore, that the student should fully know the 
symptoms of morbid processes. Each process is characterized by 
special phenomena by which it can be recognized. The symptoms 
are modified by the function and anatomical structure of the organ in 
which the process takes place. Thus the pathological products of in- 
flammation of the mucous membranes of the bronchial tubes and of 
the stomach are the same, but the symptoms differ, because of the 
difference in their functions, and hence we have cough in the former 
case, in the latter, vomiting. Very frequently the symptoms differ 
because of the physical alterations. Thus inflammation of the pericar- 
dium is similar to inflammation of the pleura, but the pressure-symp- 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY, 401 

toms of pericarditis are 'entirely different, because of the anatomical 
relations, from the pressure-symptoms of pleuritis. 

The morbid processes are not many. They include : I. Alterations 
in the blood and circulation ; II. Disturbances of nutrition ; III. 
Anomalies of growth. 

I. Alterations in the Blood and Circulation. The composition 
and distribution of the blood affect all the tissues for weal or woe. 
The quantity of the blood alone will be referred to ; changes in quality 
will be considered under diseases of the blood. Practically the symp- 
toms, when the quality is affected, are those of ancemia plus the symp- 
toms (physical and functional) of the primarily diseased organ — as the 
spleen in leucocythaemia. The quantity may be increased or dimin- 
ished. 

1. Increased Quantity of Blood, or Plethora. Formerly 
this was considered an entity, and the symptoms of flushed face, hot 
and full head, throbbing pain, throbbing temporals, a full, strong 
pulse, sluggish intellect, were thought to indicate an excess of the 
general bulk of the blood. True plethora is rarely permanent. If 
transitory, the veins and not the arteries are overfilled. The symp- 
toms are not due to general plethora but to excess of blood-pressure 
or to special fluxions of blood to superficial vessels, determined by a 
nervous mechanism. Increase in one of the cellular elements of the 
blood, the leucocytes, is not a plethoric condition. 

2. Diminished Quantity of Blood, or Anaemia. Anaemia em- 
braces the diminution of the bulk of the blood as well as of the red 
blood-cells and their haemoglobin. 

The term might be used for loss of the water of the blood, as in 
cholera Asiatica (see Infectious Diseases), or in serous purging. The 
symptoms are those of collapse. 

Oligemia or spanaemia are terms that may be used to define the 
general thinness or poverty — atrophy of the blood. Clinically, anaemia 
is divided into simple anaemia, general poverty of the blood ; per- 
nicious or idiopathic anaemia, reduction in the number of red cells ; 
chlorosis, reduction in the quantity of haemoglobin ; leucocythaemia, 
relative loss of red and increase of white corpuscles. (See Diseases of 
the Blood.) 

3. Local Disturbance of the Circulation. A. Hyperemia 
or Congestion. The process may be acute or chronic. It is usually 
local, although it may be general. When the latter, many organs may 
be simultaneously involved from a common cause. 

Acute Hyperemia. The acute or active form of hyperaemia is 
always local and arterial. There is an excess of blood in the part. 
If the skin is the seat, there are redness and increased heat, and throb- 
bing or pulsation may be seen. The parts are swollen. The excita- 
bility of the nerves is increased, with local symptoms of warmth, fulness, 
or itching. 

The morbid blushing, or flushing, that occurs at the menopause or 
reflexly from internal disorder is a hyperaemia, and in erythema of the 
skin hyperaemia is also very marked. 

26 



402 GENERAL DIAGNOSIS. 

Causes. Arterial hyperemia is caused by (1) neuroparalysis of the 
inhibitory or vasoconstrictor fibres, of the cervical sympathetic, 
splanchnic, and other sympathetic and some mixed nerves, as the 
sciatic ; (2) neurotonic stimulation of the actively dilating or vaso- 
motor dilator nerves, as the chorda tympani. There is relaxation of 
the arterial walls. This may also occur directly through the vasomotor 
system, being induced by heat, electricity, or chemical irritants, or 
from paralysis of muscular fibres, after spasmodic contraction due to 
cold, as in frost-bite. 

(1) Neuroparalytic Hyperemia. Destruction of the cervical sympa- 
thetic nerve by abscess, wounds, or a tumor pressing upon it, produces 
hyperemia of the side of the face, rise of temperature, and contraction 
of the pupil. Later on the vascular conditions are reversed. Lesion 
of the fifth nerve, or one of its branches, causes hyperemia of the iris, 
the conjunctiva, the cheek, the gums, and other structures supplied by 
it, with associate loss of sensation followed, by atrophy. The sensory 
symptoms have nothing to do with the vascular paralysis. 

(2) Neurotonic Hypoxemia. After wounds of the brachial plexus 
hyperemia of the fingers is seen. (See Fingers.) The local temper- 
ature rises and there is neuralgic pain. Local hyperemia with hyper- 
esthesia, known as erythromelalgia, belongs to the same class, being 
due to affections of the nerve-trunks, or the peripheral nerve-endings. 
It must be remembered that a reflex hyperemia is possible. 

Chronic oe Venous Hyperemia (passive congestion). The blood 
accumulates in the veins, and, by backward pressure, in the capillaries. 
The venous capillaries are over-distended and, as compared with the 
arterial, much enlarged. They contain venous blood. 

Any congested part, as the exterior, is bluish or purple in tint, 
often swollen (clubbed fingers), cooler than normal, with lessened sen- 
sation, and without pulsation. (See Cyanosis.) The dependent parts 
are first affected, as the legs, or the lungs. In fevers a weak heart and 
recumbent posture predisposes to congestion of the lungs. 

Causes. Obstructive heart and lung diseases cause general venous 
congestion. Local venous congestion is caused by tumors, the preg- 
nant uterus, or collections of faeces pressing upon the veins. It is also 
caused by inflammation of the veins, and thrombosis. 

B. Local Anjemia. This may be due to arterial thrombosis or 
embolism, arterial obstruction through endarteritis, or to arterial spasm. 
Raynaud's disease is a form of arterial spasm. The grave effects of 
arterial obstruction are seen in cerebral anemia from endarteritis, or 
myocarditis from obstruction of the coronary arteries. 

C. GEdema and Dropsy. The changes of the circulation which 
produce these conditions have been referred to in previous chapters of 
this book. The symptoms and signs of the condition are also noted 
in the same section. 

D. Thrombosis and Embolism. The student should be familiar 
with the symptoms of these conditions, and, what is fully as important, 
with the causes that give rise to them. Thrombi may form in the 
heart, the arteries, or the veins. Emboli may be formed in either 
heart or vessels, but lodge in the vessels only. 



I 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 403 

Thrombosis. The symptoms of thrombosis are : 1. Mechanical. 
The channel is obstructed ; hyperemia, engorgement, oedema, and 
cyanosis arise. Its most typical form is seen in femoral thrombosis, 
with cyanosis, and oedema of the leg. When an artery is obstructed 
the symptoms are like those of occlusion under other circumstances (see 
Embolism) ; when a vein, the mechanical symptoms vary according 
to the particular vein affected. Thus, in thrombosis of the coronary 
vein, the heart's action is interfered with. In thrombosis of the portal 
vein, jaundice (not because of the obstruction), oedema (ascites), and 
congestion of mucous membranes (gastric and intestinal) occur, as from 
obstruction in any vein. In thrombosis of the cerebral veins, disturb- 
ance of the function of the brain is seen ; of the pulmonary veins, 
dyspnoea. 2. Inflammatory or septic. If it should happen that the 
thrombosis developed secondarily to an innammation of septic origin, 
as in the extension of an innammation into the radicles of the portal 
vein from an abscess about the rectum or vermiform appendix, the 
liver would be infected with micro-organisms. An infectious inflam- 
mation with chills, fever, sweats, and other phenomena of a septic 
character would result (pyelophlebitis). 3. Embolic. From the throm- 
bus emboli are sometimes swept off ; hence, embolic symptoms arise in 
the course of thrombosis. 

While thrombosis is, as a rule, easily recognized, it is necessary to 
call attention to the very great importance of going a step farther to 
look for the cause. A thorough knowledge of the causes of thrombosis 
often leads to the diagnosis of a thrombus when without such knowl- 
edge its presence would never have been suspected. The causes are 
not many. 1. Stagnation or stoppage of blood. It is seen chiefly in 
the veins and the heart. External pressure upon the veins : as upon 
the pelvic veins in pregnancy or abdominal tumor, upon the hemor- 
rhoidal veins, upon the portal veins by tumor, upon the pulmonary 
veins by mediastinal tumor. It must be remembered that some change 
takes place in the internal coat of the vein also, but that the pressure 
is primary. Then we have weakness of the heart as a cause of stagna- 
tion. Feeble contractions lead to the formation of cardiac thrombi. 
2. Thrombosis from changes in the vessel's walls. The change is 
usually inflammatory and often proceeds from wounds. If the wound 
was septic, the inflammation will be septic. In the heart, endocarditis ; 
in the aorta, atheroma leads to the development of thrombi. 3. Throm- 
bosis from the entrance of a foreign substance into the vessels. A 
carcinoma or other new growth may extend into the veins. Micro- 
organisms penetrate the vein and cause inflammation and thrombosis, 
or infect a previously existing thrombus. The clot is then broken and 
distributed throughout the system, causing pyaemia. 4. Thrombi are 
produced by extension. A clot enlarges by coagulating the blood next 
to it. A large venous distribution may become blocked, as, first the 
uterine veins, then the internal iliac, then the external iliac, and after 
that the femoral — causing the affection which frequently occurs in the 
puerperal form, phlegmasia alba dolens. 

Embolism. An embolus is a substance which is swept into and 
plugs a vessel. It may be a fragment of a blood-clot (thrombus), vege- 



401 GENERAL DIAGNOSIS. 

tations from valves of the heart, parasites, new growths which had 
entered the veins, fat, or air. If obstruction of the vessel alone is pro- 
duced, the embolism is said to be simple ; if a new process, as inflam- 
mation, accompanies the obstruction, it is specific. Fragments from a 
thrombus in the systemic veins may become an embolus and block 
the pulmonary artery ; a clot or portion of valve-leaflet from the left 
heart may block a systemic artery, as a cerebral artery or the femoral 
artery or its branches ; a clot in the portal vein may obstruct branches 
in the liver. 

The symptoms occur suddenly and depend upon the artery obstructed. 
The cutting off of the blood-supply causes cessation of function beyond 
the point of obstruction. In pulmonary venous embolism dyspnoea is 
pronounced, the heart's action rapid and irregular, and many cases are 
said to be " heart-failure." In the middle cerebral artery the embolus 
causes aphasia and monoplegia or hemiplegia. In embolism of the 
pulmonary artery cough and hemorrhage with dyspnoea occur suddenly. 
The patient in whom this occurs usually has had antecedent mitral 
regurgitation and dilated right heart. 

The blocking of an artery may lead to various symptoms. If, for 
instance, the main artery of the leg is blocked, anastomosis may be set 
up ; if it does not, gangrene ensues. If an artery supplying any inter- 
nal organ is blocked, anastomosis may occur, if the artery is not termi- 
nal. If the artery is terminal, there results rapid necrosis or softening, 
as in the brain ; gradual wasting, as of the kidney, or engorgement of 
the arterial area and diffuse hemorrhage. The latter is known as a 
hemorrhagic infarct. This may occur in the lungs (pulmonary artery), 
spleen, kidneys, retina, and, rarely, the intestinal canal. The symp- 
toms of hemorrhagic infarct are swelling and hemorrhage. In the 
lungs, there are physical signs of consolidation, with haemoptysis, 
cough, and dyspnoea ; in the kidneys, pain and hematuria ; in the 
spleen, pain and at times enlargement ; in the retina, blindness with 
ophthalmoscopic changes ; in the intestine, pain and hemorrhage with 
sloughing of mucous membrane. Infective emboli cause abscesses. 
Capillary embolism is seen in the skin and mucous membranes in many 
infective diseases, notably ulcerative endocarditis. Fat-embolism occurs 
in the pulmonary capillaries, and is due to fat-globules which some- 
times enter the circulation in pregnant women, or in patients with bone 
disease, as osteomyelitis, or fractures. The symptoms are those of 
intense dyspnoea. It may cause sudden death. Air-embolism. Air 
may enter wounds of the veins of the neck. It accumulates in the 
heart, and as the ventricle cannot contract on it the blood is not pro- 
pelled. Death takes place with the symptoms of heart-clot, the heart 
being in asystole. 

Hemorrhage. Hemorrhage may be arterial, venous, or capillary. 
It may occur because the blood soaks through the walls, by diapede- 
sis ; or it may occur from rupture, or rhexis. Hemorrhage by dia- 
pedesis takes place in venous engorgement, stasis, or inflammation. It 
is the small passive hemorrhage of congestion, as in pulmonary conges- 
tion from heart disease ; it is venous or capillary ; the blood is dark. 
Hemorrhage by rupture is arterial, venous, or capillary. If the artery 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 405 

ruptures, it has been torn by violence, destroyed by ulceration or sup- 
puration, or it is the seat of endarterial change. Veins are also diseased, 
or their walls destroyed, before rupture takes place. Rupture of capil- 
laries occurs from violence or great internal pressure. In death from 
suffocation the capillaries are the seat of hemorrhage because of the 
increased venous pressure. Such capillary hemorrhage occurs in 
typhus, hemorrhagic smallpox, and scarlatina. The state of the blood 
is sometimes the cause of hemorrhage, as in scurvy, purpura, and other 
conditions. Hemophilia is a peculiar hereditary affection possibly 
due to the state of the blood, more likely, however, due to the condi- 
tion of the bloodvessels. 

The special forms of hemorrhage and their symptoms, etiology, and 
diagnosis will be considered in the sections to which the names in the 
following list point : 

Bleeding from the nose — epistaxis. 

Vomiting of blood — hcematemesis. 

Bleeding from the lungs — hcemoptysis. 

Blood passed with the urine — hematuria. 

Blood passed from the uterus — Menorrhagia or metrorrhagia. 

There is also intestinal hemorrhage — mekena. 

Hemorrhages underneath the skin are known as petechial if small, 
and ecchymoses or suffusions if large. 

Hemorrhage into internal organs receives its name from the organ 
affected, and is known as a parenchymatous hemorrhage. Apoplexy is 
applied to hemorrhage into the substances of organs, particularly if it 
occurs suddenly and is localized — as pulmonary apoplexy, cerebral 
apoplexy, spinal apoplexy. Long usage has associated the term with 
hemorrhage into the brain, so that it is applied to that form alone by 
most writers. Ho3matoma, or blood-tumor, is a collection of blood that 
has coagulated in a cavity, organ, or tissue. (See Ear.) 

The symptoms of hemorrhage vary in degree, depending upon the 
amount of blood which escapes from the vessel, and whether the hem- 
orrhage is external or internal. By external hemorrhage we mean one 
which is accompanied by a discharge of blood visible to the bystander. 
An internal or concealed hemorrhage is not apparent by any outward 
sign of blood. 

The symptoms by which external hemorrhage is recognized need not 
be detailed. The show of blood in situations or at times other than 
normal is sufficient. It must be remembered that arterial blood is 
bright red, venous blood dark. It must also be remembered that the 
character of the blood coming from internal organs is modified by the 
secretion of the affected organ. Thus the blood from the stomach is 
coagulated and black, like coffee-grounds ; blood from the intestine, 
tarry. The general symptoms of the various degrees of external hem- 
orrhage are similar to the symptoms of internal hemorrhage, which 
will be described later. Both vary with the rapidity of the flow of 
blood. If the bleeding is slow, large quantities may be lost and more 
or less profound anaemia result. It is often more difficult to determine 
the source of hemorrhage. The mode of recognition of the anatomical 
varieties of hemorrhage will be discussed under the respective systems 



406 GENERAL DIAGNOSIS. 

which are the seat of the bleeding. Hemorrhage may take place in a 
cavity, as the stomach, bowels, or bladder, and after the blood has 
undergone changes it may cause symptoms of, and be discharged as, 
a foreign body. 

Although internal hemorrhage presents vivid phenomena, they may 
not be characteristic, and its recognition is often impossible without 
some knowledge of the history of the case. The symptoms are com- 
plex. First, we have pain, a symptom due to rupture of a vessel or 
to the filling of a tissue with blood. In the beginning the pain is 
sharp, severe, and of itself may cause shock. In the second place, the 
symptoms due to loss of blood arise. After pain, sudden prostration 
ensues ; pallor spreads rapidly ; the extremities become pallid and 
cold ; a cold sweat breaks out on the forehead ; the features become 
pinched and shrunken ; the pulse becomes weak and rapid, and later 
thready, or disappears altogether at the wrist ; the carotids pulsate ; 
the heart throbs violently and a diffuse impulse is seen, at first vigor- 
ous, soon like a slap against the chest-wall, and then it fades away 
completely. On examination of the heart and vessels so-called anaemic 
murmurs are heard. The patient is restless, and sighs and yaAvns 
frequently. The respiration becomes slow and shallow. Nausea and 
sometimes vomiting may occur. He may faint but once or repeatedly, 
to be restored again and again, or the syncope may terminate in death. 
In the intervals between the syncopal attacks the mind is clear. If, 
however, profound shock is associated Avith the hemorrhage, there is 
dulness or stupor ; the intellect is dazed ; otherwise delirium and agi- 
tation may be present. When the hemorrhage is profuse convulsions 
may take place. The temperature of the body falls. If the patient 
has fever at the time, the temperature suddenly falls to or below nor- 
mal. We have, therefore, the following conditions in hemorrhage : 
syncope, shock, and collapse. They may all be present in the same 
subject, or one or two may be absent. The same symptoms may, how- 
ever, occur from other causes, which must be excluded. Sometimes the 
shock may be due to the same cause as the hemorrhage. The causes of 
shock are so evident that they serve to distinguish it from the collapse 
of hemorrhage. They are injury, anaesthesia, railway accidents, surgi- 
cal operations, perforative peritonitis, strangulated hernia, intestinal 
obstruction, profound mental impression, and pain. 

Shock from hemorrhage must be distinguished from concussion. 
In the latter the intellectual disturbance occurs at once, and is more 
marked than the circulatory symptoms. The absence of the usual 
phenomena of hemorrhage serves to distinguish syncope due to concus- 
sion from that due to the many well-known causes of fainting. 

There are many forms of internal hemorrhage sufficiently grave to 
have a probably fatal result, or at least to create alarming symptoms. 
In the chest, diseases of the lungs or the aorta cause hemorrhage. In 
concealed pulmonary hemorrhage the blood accumulates in a large 
phthisical cavity. When the aorta or an aneurism ruptures the blood 
may enter the mediastinum or the pleura. Under these circumstances 
a knowledge of the previous history is essential. Careful examination 
of the lungs or of the heart or bloodvessels must be made in a case 



MORBID PRO CESSES AND THEIR SYMPTOMATOLOGY. 407 

which presents the above-mentioned symptoms of internal hemorrhage. 
Internal concealed hemorrhage into organs or cavities of the abdomen 
occurs in gastric, duodenal, or intestinal ulceration ; in aneurism or in 
ulceration of large vessels, from septic inflammation around them. It 
must not be forgotten that alarming or fatal internal concealed hemor- 
rhage may be due to haemophilia or purpura. 

II. Disturbances of Nutrition. 

Hypertrophy and Atrophy. (See the Size, Chapter VI., and 
Muscles.) 

Inflammation. Inflammation, a process largely attended with vas- 
cular alteration, but also with disturbance of nutrition. It may be 
acute or chronic. It is due to injury, mechanical, physical, chemical, 
or vital. The invasion of micro-organisms or the irritation of their 
products is the most frequent cause in cases that come within the 
province of the physician. The symptoms are modified by the struc- 
ture affected and by the cause of the inflammation. The intensity and 
the character also modify them. The classical symptoms —pain, heat, 
redness, and swelling — are indicative of the tissue-process. In addition 
we have exudation and alteration of function. Pain varies in degree 
with the sensibility of the part. It is increased by pressure or move- 
ment, and by the functional activity of the affected organ. Heat is 
detected by the hand or surface-thermometer. It may be described by 
the patient, in abscess within the peritoneum, or pyosalpinx, as a ball 
of fire. The surface-temperature over an inflamed lung or pleura is 
higher than over the healthy side. Redness can only be observed in 
parts open to inspection, as the nasal, oral, faucial, and other cavities. 
Swelling is observed with the redness ; it is shown by enlargement of 
the affected organ, if the latter can be measured by palpation or per- 
cussion. Exudation takes place from mucous surfaces, into serous 
cavities, into the connective or any affected tissue, or into tubes or 
channels (heart and bloodvessels, lymphatics, etc.). The symptoms 
are : characteristic discharges from mucous surfaces ; pressure and 
physical signs from accumulation in cavities ; symptoms of the obstruc- 
tion of channels. Grave pressure-symptoms arise when the exudation 
presses upon the nerves, nerve-centres, or nerve-tracts (brain cord, 
peripheral nerves). The pressure-symptoms are often more pronounced 
than the inflammatory in simple or tuberculous meningitis. Alteration 
of function : The symptoms cannot be detailed here ; each organ and 
structure must be referred to. The function may be stimulated at 
first, but is soon perverted, or suppressed. 

General Symptoms. Fever is the general expression of the local 
process. It may be primary from reflex irritation of afferent nerves 
which influence the heat-centre and disturb the thermotaxic mechan- 
ism. It may be secondary, the products of inflammation (pus, toxins, 
etc.) irritating the centres. The degree depends upon the cause. Active 
inflammation may not be attended by fever. 1 

Suppuration. The character of the fever indicates the variety of 

1 Musser : "Abscess of Liver," Univ. Med. Magazine, 1892. 



408 GENERAL DIAGNOSIS. 

the inflammatory process. In most inflammations the fever is con- 
tinuous. When there is suppuration, however, it becomes intermittent 
or remittent. The presence of suppuration is also made known by 
hectic, in which the fever is attended by chills and sweats. The appe- 
tite is lost or impaired. There is also leucocytosis. The urine con- 
tains a large amount of indican. In obscure inflammations about the 
peritoneum the indicanuria points to a suppuration. While fever- 
symptoms in inflammation are similar, save in degree and in the pecu- 
liar type of the temperature-range — intermittent, remittent, or contin- 
uous — septic inflammations are attended early by cerebral symptoms, 
prostration, and the typhoid state. (See Fever, pages 218 and 224.) 

As a corollary, when fever is present, local inflammation must be 
sought for. Chronic inflammations may only give rise to altered func- 
tion and cause exudation (swelling, effusion, etc.). 

Inflammation of Various Structures. The symptoms vary according 
to the anatomical and physiological peculiarities of the structure. 

Inflammation of mucous membranes. Pain is not excessive ; heat is 
complained of (rectum) ; redness is marked and varies with the in- 
tensity from bright to dark red ; swelling is always present. In narrow 
channels, as the nose, or the gall-ducts, it causes occlusion. The 
exudation is at first mucous, then mucopurulent, and then purulent. 
Before exudation there is a stage of dryness. The microscopical 
appearance of the exudate varies with the anatomical character of the 
membrane affected. Its peculiar epithelium is always present, also 
micrococci, pus, red cells ; from the lungs or liver, special crystals. 
The functions are impaired. Fever is usually not very high and is 
continuous. The causes are direct local irritants or congestions from 
external impressions (cold ?). 

Inflammation of serous membranes. Pain is extreme and may cause 
collapse. Heat, swelling, and redness cannot be estimated. The surface- 
temperature rises. Exudation occurs after a brief dry stage. The 
cavities — pleura, pericardium, peritoneum, joints, cerebro-spinal canal 
— are filled, causing mechanical symptoms and physical signs. Fever 
is excessive in some forms. Function is impaired or abolished. Gen- 
eral symptoms are more pronounced. Shock or collapse is common in 
peritonitis. The affections are always secondary to a general process 
(rheumatism), to infection, to disease of neighboring structures, or to 
Bright' s disease, diabetes, cancer, scurvy, or other diathetic condition. 

Inflammation of muscles (rare), of connective tissue, and of glands is 
characterized by symptoms common to the morbid process, with alter- 
ation of function. 

Inflammation of bone and periosteum presents the same group of 
symptoms. The pain may be intense or of a dull, aching, or boring 
character. 

Inflammation of the heart and vessels is also attended by the cardinal 
symptoms. When the central organ is the seat of the disease pain is 
not common, but in the arteries or veins it is of frequent occurrence. 
The striking symptom, however, is the obstruction to the channels. 
It is characteristically seen in phlebitis, as of the femoral vein. 
CEdcma of the leg, and cyanosis, reveal the obstruction. In the heart 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 409 

the acute process or the results of the process give rise to all the symp- 
toms of obstructive heart disease. 

Inflammations of the nerves, the spinal cord, and the brain are fol- 
lowed more strikingly by pressure-symptoms and by the symptoms of 
degenerations secondary to the inflammatory process. Hence, while 
pain and tenderness are present in the exposed nerves, increased irrita- 
bility, then abeyance, perversion, or abolition of function are the princi- 
pal signs of inflammation of these regions. 

Inflammation of internal organs, lung, liver, kidneys, and pancreas, is 
made known by pain (minimum amount) and swelling (enlargement of 
liver), and by change in the function, indicated by modifications of the 
respective secretions as well as by functional and physiological symp- 
toms. 

Local Death, Necrosis, and Gangrene. If nutrition is not 
complete, the life of the cell is endangered. This process is known as 
necrosis or gangrene. The nutrition is annulled : 1. By stoppage of 
the circulation. 2. By the direct action of an irritant which destroys 
the cells. 3. By abnormal temperature. A combination of the three 
causes quickly produces gangrene. Stoppage of the circulation may 
be due to an embolus or thrombus, or to stagnation by pressure, or to 
capillary stasis alone. Sloughing and " bed-sores " ensue in the latter 
instance ; gangrenous eschars in the former. The cells are destroyed 
by corrosives and caustics, by heat and cold, by bacteria. Where 
decomposition takes place, as in retained and infiltrating urine, cell- 
destruction and sloughing ensue. All pathogenic bacteria cause necro- 
sis to a greater or less degree. Frost-bite and burn illustrate the destruc- 
tive power of abnormal temperature. 

Nerve-lesions, trophic disorders, produce necrosis. We have, allied 
to bed-sores and known as decubitus, a form of necrosis in spinal-cord 
diseases. The sloughing is extensive and rapid. Trophic disorders 
cause paralytic hypersemia, and hence necrosis. 

It must not be forgotten that debility, cachexia, and feeble circula- 
tion play a great part in assisting the local changes. 

Gangrene of internal structures concerns us. This form is nearly 
always due to stoppage of the circulation. It is seen in constriction 
of the intestine, from hernia, or obstruction. It occurs in phthisis 
from thrombi. Clinically, we see it frequently in diabetes. The lung, 
the brain, the intestines, are most frequently affected. 

The symptoms of necrosis or gangrene are modified by the tissue 
involved, the function interfered with. If external, the decomposing 
structures emit a foul odor, there is rapid prostration and development 
of the typhoid state. Fever ensues from intoxication by decomposing 
substances — saprsemia. Often the symptoms are latent. A man aged 
sixty, in my ward, was about all the time. He died suddenly of pul- 
monary hemorrhage, the result of gangrenous ulceration of a large 
vessel ; at the autopsy gangrene of the lung was found. The only 
symptom was the characteristic odor. In the course of inflammatory 
processes the onset of gangrene is frequently attended by the cessation 
of pain, the peculiar odor when it communicates with the exterior, and 
the development of exhaustion and the typhoid state. The character 



410 GENERAL DIAGNOSIS. 

of the discharge points to gangrene. When the lungs are affected 
the expectoration is like prune-juice ; when the bowels, the discharge 
is dark and putrid. 

Fever is a morbid process, with the cause and symptomatology of 
which the student must be familiar. It has been fully treated in 
previous chapters. (See Fever.) 

The Degenerations. The symptomatology varies with the form 
of degeneration and the organs affected. The prostration of the gen- 
eral economy is due to the same cause as the degenerations themselves. 

Albuminous degeneration occurs in fever, and causes the weak heart 
and defective gland action. The weak heart of the convalescent period 
in diphtheria and other infective diseases is well known. 

Fatty Degeneration and Infiltration. In fatty degenera- 
tion there is cell-destruction. The brain, the heart, the kidneys in 
Bright' s disease, the liver, all undergo degeneration. It may be due 
to phosphorus-poisoning or to snake-bite. It is seen in acute yellow 
atrophy of the liver. It is caused by other toxic agents. Fatty infil- 
tration or lipomatosis is seen in the ' ' fat " heart of brewers, the en- 
larged liver, the excess of fat in the abdomen, etc. The affected 
organs are enlarged, but they are functionally weak. Fatty infiltra- 
tion of organs is recognized by its etiological associations. In alco- 
holic subjects of sedentary habits, in subjects who eat an excess of 
fatty foods, in overfed and pampered children, and in tuberculosis it 
is commonly seen. In fatty infiltration the cells are not destroyed. If 
with the above conditions the liver is enlarged or the heart weak, or 
both, we may expect to find fatty infiltration. There is enlargement 
of the affected organ, which is painless, smooth, not usually soft on 
palpation. The condition occurs at any age, but usually in later life. 
Emaciation may not be present. Lithsemia is common in fatty infil- 
tration. 

Amyloid Degeneration. This is rarely confined to one organ 
of the body. The causes are syphilis, malaria, tuberculosis, and pro- 
longed suppuration. The liver and spleen are enlarged, hard, smooth, 
and painless. There are great pallor, and oedema of the feet and face. 
There is ancemia, but no fever. The kidneys are affected, hence poly- 
uria and low specific gravity of the urine ; a few casts are found. The 
bowels are likely to be loose because the process has involved the intes- 
tine. It occurs at any age. The diagnosis rests on the presence of a 
cause, the painless enlargement of organs, the pallor, and the polyuria. 

Fibroid Degeneration. This is not so much a degeneration as 
an overgrowth of connective tissue with coincident primary or second- 
ary atrophy of the parenchyma. The function of the organ is impaired 
or abolished. Increase of connective tissue in the nerve-structures 
is known as sclerosis, in the liver or kidney as cirrhosis. In the 
artery it leads to the changes knoAvn as endarteritis. Whatever the 
pathology may be, whether atrophy of cell-elements of the affected 
structure be primary or secondary, the condition is productive of seri- 
ous, even grave consequences. It is part of the senile process. It 
leads to the manifold symptoms of endarteritis ; it is the cause of 
many nervous affections which will be discussed in their proper sections. 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 411 

The varied phases of so-called interstitial nephritis are due to the 
fibroid changes primarily in the kidneys, and secondarily in the arte- 
rial system. In the lungs it attends emphysema, or may even be pro- 
ductive of that condition. The fibriod heart, is another manifestation 
of the same process. The tubes and channels are closed by the same 
process as in fibrous stricture of the duodenum. Wherever situated 
its development means gradual abolition of function. 

Mucous Degeneration. This form of degeneration is seen in 
myxoedema. The albuminous intercellular substance is replaced in 
the connective tissue by mucin. 

Pigmentary, calcareous, and colloid degenerations are local morbid 
processes without other symptoms than those of the primary affection. 

III. Anomalies of Growth. 

Tumors. Tumors, other than cancer or sarcoma, produce only 
mechanical symptoms, and must be considered in their special section. 
The mechanical symptoms are due : 1. To the tumor (foreign body). 
2. To obstruction of any channel in near relation. 

New Growths. They cause local symptoms. This is most striking 
in structures which must necessarily be destroyed as the growth in- 
creases in size, as in the brain or spinal cord, or where tubes or chan- 
nels are closed, as in cancer of the stomach or oesophagus. Local symp- 
toms may precede the general symptoms ; on the other hand, general 
symptoms may arise for which no local cause can be assigned. The 
local symptoms of cancer are variable and depend upon the anatomical 
nature and physiological offices of the organ affected, and upon its 
anatomical relation to surrounding organs. This class of symptoms 
will be referred to in the section on special diagnosis. Suffice it to 
say they cause gradual abolition of the function of the organ, or closure 
of the channels in connection with it, as the intestinal canal, the pharynx, 
or the hepatic ducts. Cancer and sarcoma are accountable for a group 
of symptoms to which the term cachexia has been applied. In acldi- 
dition, a few symptoms belong to the cancerous process wherever situ- 
ated. They may or may not all be present ; in the large majority of 
cases one or more are wanting ; they should always be sought for in 
order to confirm a diagnosis of cancer. These symptoms are : 

1. Pain, recognized by peculiar characteristics in most cases : (a) It 
is sharp and lancinating ; (b) it is paroxysmal ; (c) it is increased by 
irritation, as food when the stomach is affected ; (a) it is increased by 
functional activity, as speaking or swallowing in carcinoma of the 
larynx or pharynx ; (e) at the outlet of canals, as the bladder or 
rectum, it gives rise to tenesmus. 

2. Hemorrhage. If the malignant mass is in communication with 
the exterior, the blood may be discharged per vias naturales. In malig- 
nant disease of the upper air-passages or the lungs hemorrhage is 
likely to occur. It is common in gastric carcinoma as well as in 
uterine cancer. If the organs do not communicate with the exterior, 
and the lesion gives rise to exudations or transudations, the latter are 
frequently bloody, as in carcinoma of the pleura or peritoneum. 

3. Abnormal Discharge. This occurs especially in cancer of the 



412 GENERAL DIAGNOSIS. 

hollow viscera and of the canal-structures. The discharge is the result 
of inflammation, suppuration, and necrosis, and particularly microbic 
inflammation. It is recognized by its more or less bloody character 
and by its odor, which is peculiar. It is most offensive and pene- 
trating, and, particularly in uterine cancer, is almost pathognomonic. 
Even the utmost cleanliness will not obviate it. 

4. Tumor. It may be readily detected or elude all search. Some 
swelling is certainly present. It is discovered by external examina- 
tion, by the objective physical signs of enlargement or change of con- 
tour of the affected organ. 

5. Foreign Body. The growth gives rise to symptoms similar to 
those present when a foreign body is fixed in any portion of the 
hollow viscera, as the respiratory tract, the gastro-intestinal, including 
the hepatic and the genito-urinary tract, a. Through reflex influence 
an attempt is made to remove it, hence cough, vomiting, diarrhoea 
with tenesmus, repeated and painful micturition with tenesmus, etc., 
the particular symptoms varying with the organ affected, b. Obstruc- 
tion of the channels, with all the accompanying symptoms, depending 
upon the location of the growth. 

6. Temperature. A morbid process is often recognized by its nega- 
tive symptoms, if the term may be used. Thus, fever is absent or the 
temperature is even subnormal in carcinoma. 

7. The Cancerous Cachexia. Wherever situated the disease is 
sooner or later attended by extreme general symptoms which are, in 
a measure, striking. It is to be admitted that cases of carcinoma often 
occur without marked cachexia, a. One symptom may always be 
looked for ; it is emaciation. It may be rapid or gradual and extend 
over one or two years ; toward the end it is always rapid. Ultimately, 
if the patient does not succumb to other conditions, it presents an ex- 
treme picture. The eyes are sunken, all normal accumulations of fat 
disappear. The fat in the rectal fossse disappears, causing deep de- 
pression of the rectum. The abdomen is retracted. The appearances 
are most striking in cancer of the oesophagus, b. Pallor (see Color) ; 
this may be present, c. Anwmia, with breathlessness, palpitation, 
vertigo, d. Exhaustion. This with accompanying emaciation is pro- 
gressive, and may be the first symptom. Progressive weakness is 
often seen without fever or local disorder to account for it. Toward 
the end it becomes so extreme as to forbid exertion, e. Malnutrition. 
Evidences of malnutrition appear ; the skin is hard and dry ; its elas- 
ticity is impaired and it becomes the field for parasitic invasion. 
Tinea and other parasites may flourish. Bacteria invade the suscepti- 
ble areas, and boils make their appearance. The secretions are per- 
verted. In the mouth ulcers develop ; the fungi of this situation (the 
throat, etc.) become more active ; the gums are inflamed. In the later 
stages the "typhoid state 7 ' (see Fever) may ensue. If the gastro- 
intestinal tract is invaded, symptoms of acute intoxication may arise. 

8. Metastasis. We are often aided by the occurrence of this event, 
particularly by involvement of the glands. In gastric carcinoma 
secondary hepatic disease or enlarged glands above the left clavicle 
are found ; in rectal carcinoma, secondary hepatic cancer. In many 



MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 41 3 

instances the presence of cancer is revealed by the metastasis, even 
when the primary growth cannot be recognized. 

The diagnosis rests upon the above conditions. In obscure cases 
the age, the sex, the associate pathological conditions, the duration of 
the disease become important factors in the diagnosis. Cancer usually 
occurs after forty, or, some authorities say, after fifty years of age. 
The female sex is most frequently affected. It may be associated 
with a history of previous lesion or irritation, as ulcer in vaginal, 
gastric, or rectal cancer ; the irritation of teeth or a pipe in labial and 
lingual cancer ; of gallstone in cancer of the bile-ducts ; of renal or 
visceral calculus in disease in that situation. A disease of grave and 
malignant character, the duration of which is over eighteen months or 
two years, is not, in all probability, cancer. 

Morbid Processes in Tubes or Channels. The effects produced by 
obstructions. 

When tubes or channels are the seat of disease symptoms arise apart 
from the special morbid process, which are due to obstruction and are 
common to all tubes or channels. The symptoms of obstruction of the 
bloodvessels and lymph-channels — cyanosis, oedema, gangrene (throm- 
bosis and embolism) — have been described. But in addition we have 
hypertrophy, a secondary condition, not referred to above, which, 
nevertheless, follows obstruction of any channel. In the cases of vas- 
cular obstruction the hypertrophy is seen in the heart and the arteries. 
(See Diseases of the Heart.) 

In obstruction, therefore, of tubes or channels we have to a greater 
or less extent (1) hypertrophy behind obstruction ; (2) diminution of 
the normal flow of fluid and consequent accumulation of material 
which normally passes through the channels ; (3) atrophy and cessa- 
tion of functional activity beyond the point of obstruction ; (4) dilata- 
tion of the primary hypertrophy ; (5) degeneration, ulceration, low- 
grade inflammation (bacterial), secondary rupture of the affected 
viscera. The morbid anatomist can readily point out the examples of 
the morbid changes sequential to obstruction. Thus in cancer of the 
oesophagus there are hypertrophy of the muscular coats, regurgitation 
of food, atrophy of the stomach, dilatation with accumulation of food, 
secretions from the glands of the oesophageal mucous membrane, 
secondary ulceration, rupture into the lungs, with gangrene or pneu- 
monia. In obstruction at the pylorus there are (1) hypertrophy ; (2) 
accumulation ; (3) intestinal atrophy ; (4) dilatation of the stomach, 
with its train of symptoms. In obstruction of the biliary channels, 
or the bladder, or ureters, the same secondary conditions arise plus 
obstruction to the flow of bile or urine. Secondary symptoms arise 
from accumulation of the non-escaping fluids. Subjective symptoms, 
it may be said, are not marked ; there are pain and difficulty in the 
performance of the usual functions. It need scarcely be said that the 
obstruction sometimes gives rise to symptoms which are due to the 
abnormal obstructing material which acts as a foreign body. The 
symptoms are reflex and depend entirely upon the seat of the foreign 
body. 



414 GENERAL DIAGNOSIS. 

The causes of obstruction in whatsoever channel situated are, first, 
pressure from disease outside (growths, hernia) ; second, disease of the 
walls, with contraction ; third, occlusion by a foreign body, as gall- 
stone, renal calculus, worms, or other material according to the channel 
obstructed. The symptoms are most marked when the obstruction is 
due to disease outside the walls or to obstruction by occlusion within 
the walls. 

In all cases of obstruction, nasal, faucial, laryngeal, bronchial, oesoph- 
ageal, gastro-intestinal, biliary, renal, or pancreatic, look for the symp- 
toms of the secondary morbid change. Each form of obstruction will 
be specially considered elsewhere. (See Special Diagnosis.) 

The Bloodvessels. Blood-pressure. It must not be forgotten 
that the bloodvessels are in a measure distinct from other tubes, 
although subject to the same laws, physiological and pathological. 
They contain fluids, and have a continuous function by which the 
fluids are propelled. They are subject to the laws that govern the flow 
of fluids under all circumstances in nature. Any derangement or 
disease will effect changes which are explainable by hydrostatic or 
hydrodynamic laws. Fluids within vessels exert pressure. Pressure 
produced by weight of the fluid is known as the hydrostatic pressure ; 
that produced by the flow is known as the hydrodynamic pressure. 
Pressure can be gauged by proper instruments. In the case of fluid 
in the bloodvessels it is called the blood-pressure. The blood- 
pressure is estimated at the pulse by the educated finger and by the 
sphygmograph. A certain definite pressure is always present in 
health. It is subject to slight fluctuations, but tracings with a sphyg- 
mograph follow a definite course. In the description of the pulse, 
modifications of blood-pressure will be given in detail ; it is sufficient 
here to say a few words regarding hydrostatic and hydrodynamic 
pressure. 

Hydrostatic pressure is modified by the weight of the fluid. It is 
of pathological importance in the veins only, and especially in those of 
the lower limbs. When the pressure is increased the increased weight 
of the blood-column causes increased bulk and over-distention, as in 
varicose veins, unless the support to the blood-column is increased. 
Inflammations of the lower limbs are attended by venous accumulation 
and followed by ulceration. For this reason dropsies arise more 
readily in these portions. The common occurrence of gout in the feet 
may be due to slow circulation. 

Hydrodynamic pressure is variable. Its changes indicate increase 
or diminution of blood-pressure. The bloodvessels are resisting elastic 
tubes ; the resistance is always equal to the pressure within, hence 
blood-pressure and arterial tension are equivalent terms. We speak 
of increased or diminished pressure, or correspondingly of high or low 
tension. Now, the hydrodynamic or blood-pressure depends upon : (1) 
Variations in the volume of blood ; (2) variations in the capacity of the 
vascular system ; (3) facility of the capillary circulation ; (4) the force 
of the heart. The tension of the artery depends upon the same 
conditions. 



MORBID PR CESSES AND THEIR S YMPTOMA TOL OGY. 415 

1. Variations in the volume of the blood, a. Volume increased. 
Causes : absorption of fluid after meals or drinking to excess. Result : 
increased blood-pressure and increased tension. Controlled in health 
by action of the vasomotors relaxing the vessels, and by enlargement 
of the veins. b. Volume diminished. Cause : hemorrhage, serous 
purging. Result : diminished blood-pressure, lowered tension. Con- 
trolled in health by contraction of arteries through vasomotor nerves. 
In hemorrhage the loss of blood produces anaemia. The latter is a 
stimulant to the vasomotor centre in the medulla, and produces con- 
traction of peripheral arteries and high tension. 

2. Variations in the capacity of the vessels, a. Diminution of the 
capacity of the blood-channels (volume of blood not lessened). Cause : 
cutting off of a vascular area by ligation or obstruction, by narrowing 
the calibre of the wall, as in arterial spasm or endarteritis, by disease 
of the kidneys, contracting the lessening channels in the aortic circuit, 
or disease of the aorta, causing obstruction to the outflow of blood. 
Result : increased pressure, high tension. Controlled by normal regu- 
lating vasomotor apparatus, or by diminution of the volume of blood. 
b. Increase of capacity of blood-channels. Cause : relaxation of mus- 
cular coats of vessels. Result : diminished blood-pressure, lowered 
arterial tension. Controlled by contraction of vessels or increase in 
amount of blood. In shock, the vasomotor sympathetic system of the 
splanchnic arteries is so disturbed that the arteries are dilated and all 
the blood is sent into the abdominal vessels (fall of pressure). 

Mode of action of the vasomotor apparatus. Centres in the medulla, 
in the spinal cord, and locally in the sympathetic ganglia of different 
parts, control the vasomotor nerves, which influence hydrodynamic 
pressure. 1. If the centres are stimulated, tonic contraction of the 
vessels is produced. This may be general or local. Increased press- 
ure or heightened tension is the result. It may be reflex from the 
periphery, or due to some state of the blood. 2. If the centres are 
paralyzed, or inhibited, or cut off from the arteries, the latter become 
relaxed (dilated). The pressure is lowered, the tension is less. Shock, 
pain, certain drugs, reflexes (probably) produce inhibition. 

3. Facility of capillary circulation. Obstruction to outflow of blood 
from capillaries into the veins increases blood-pressure. Cause : the 
same as when arteries contract. Result : increased blood-pressure, high 
tension. Regulated in the same manner as arteries. Relaxed capilla- 
ries produce opposite conditions. 

4. The force of the heart, a. Heart's action (left ventricle) increased. 
Cause : hypertrophy, palpitation. Hence the greater force of blood- 
impact, greater resistance by arteries. The tonic resistance narrows 
the calibre of the vessels. Result : increased pressure, higher tension. 
b. Heart's action weakened. Hence, less force of blood, less resistance. 
Result : lessened pressure, low tension. 

The recognition of variations in tension. (See Pulse.) 

1. High arterial pressure or tension. By (a) incompressibility and 

tension of the arteries ; (b) accentuation of the aortic second sound ; 

(c) prolongation of the left ventricle first sound ; (d) increased flow of 

urine, pale and watery ; (e) characteristic pulse-tracing by sphygmo- 



416 



GENERAL DIAGNOSIS. 



graph. If the high tension is permanent, (/) hypertrophy of the 
heart ; (g) atheroma, more or less. 

2. Low arterial pressure or tension. By (a) soft, compressible, often 
dicrotic pulse ; (b) enfeebled sounds, aortic second and left ventricle ; 
(c) scanty, high-colored urine ; (d) special pulse-tracing. If perma- 
nent, stases, congestions, cyanosis, with general weakness and impaired 
nutrition. 



PART II. 

SPECIAL DIAGNOSIS. 



CHAPTER I. 

THE NOSE AND LARYNX. 

The Nose. 

The symptoms of disease of the nose result from disturbance of the 
function or alteration of the structure of the organ and the morbid 
process. Physiological symptoms : Impairment of the sense of 'smell, 
anaemia, and symptoms of obstruction may occur. Obstruction causes 
retention of secretions. These secretions are exposed to infection. 
Putrefaction and fermentation set in and give rise to offensive odors. 
More serious is the effect of the obstruction on the rest of the respira- 
tory tract. The patient becomes a mouth-breather. The appearance 
of the face is altered ; the voice changes, snoring is common, mastica- 
tion is interfered with, and there is a diminution in the amount of air 
passing to the lungs. As a result a vacuum is created which is com- 
pensated for by external pressure. In children the result is marked 
deformity of the chest, leading to the development of the " pigeon " or 
" chicken breast." (See the Lungs, Chapter II., Part II.) The general 
symptoms attending mouth-breathing will be referred to again. 

Symptoms due to the Anatomical Structure. The nose is an open space 
or a series of air-spaces lined with mucous membrane. The mucous 
membrane is the frequent seat of infectious inflammation, as in hay 
fever, influenza, and measles. . Most of the nasal symptoms are due to 
disease of the mucous membrane. The membrane is subject to affec- 
tions that are common to all mucous membranes, and the subjective 
and objective symptoms are similar to those that arise in other organs, 
modified by the function and anatomical arrangement. 

The abundance of bloodvessels and glands is the cause of one of the 
symptoms — namely, the discharge. Moreover, the difficulty of removing 
the discharge from the various cavities in the nose in which they are 
pent up leads to putrefaction and odor. Because the air is constantly 
passing over the parts, discharges are very liable to become dry, and 
hence crusts and scabs form. Again, the vascidarity of the structures 
of the nose is the cause of development of symptoms. The blood- 
vessels are richly supplied with nerves, which cause them to contract 
or dilate, on comparatively slight provocation, by reflex action. Chilli- 
ness of the body, or of local areas of the body, chilling of the extremi- 

27 



418 SPECIAL DIAGNOSIS. 

ties, and other peripheral impressions, are followed by congestion of 
the nasal mucous membrane, which may go on to inflammation. The 
vascularity predisposes to hemorrhage. 

The nose is richly supplied with nerves (in addition to the olfactory 
nerve), which are susceptible to various irritations or impressions — 
impressions made by the air laden with unusual material, as fumes of 
a chemical nature, emanations from animals, or plants, and certain 
substances not yet isolated, which are decidedly irritating. There 
is often local irritation from polyps and adenoid growths, and foreign 
bodies, or enlarged bone. The nerves are connected by a mechanism 
directly with the centres in the medulla, with particularly the pneumo- 
gastric centre. The effect of peripheral nasal irritation may be felt 
reflexly in the area of distribution of that nerve ; hence an unpleasant 
odor may bring on sudden nausea or vomiting. But of more striking 
and frequent pathological significance is the occurrence of asthma, or 
sudden dyspnoea, from reflex excitation of the pulmonary division of the 
pneumogastric nerve. 

Morbid processes in the nose are symptomatic of some general affec- 
tions. The occurrence of asthma, or of deformity of the chest and 
general ill-development, has been spoken of. Acute inflammations are 
significant of the exanthematous diseases, particularly measles. An 
acute inflammation (as pointed out by Meigs), with great obstruction 
of the nares and an abundant, puriform discharge, is a complication or 
symptom of Bright 7 s disease that may portend the onset of uraemia. 
Chronic inflammations may be due to syphilis or other chronic infection. 

The Data Obtained by Inquiry. 

Of the data obtained by inquiry, that belonging to the social history, 
the family history, and the history of previous diseases yield but 
little information of diagnostic value. It is true the acute inflamma- 
tions secondary to measles and other exanthemata occur at an early 
age, while the chronic attacks occur late in life, as do also tumors, 
except adenoid. Foreign bodies are more likely to be found in chil- 
dren and the feeble-minded. Those occupations which are in-doors, in 
overheated apartments, and among noxious vapors predispose to 
catarrhs. In the family history we must look for gout, rheumatism, 
syphilis, and affections which lead to osseous changes. More marked 
than all is the influence of syphilis. A chief predisposing factor in 
the production of nasal disease is the morphological arrangement of 
the parts, which may be congenital, or the result of early infantile dis- 
ease. Thus, when congenital, the high palatal arch, etc., is looked 
upon as the stigmata of degeneration. 

On inquiry of the history of previous diseases, we look for syphilis, 
the exanthemata of early life, the occurrence of gout or rheumatism, 
and of those gastrohepatic and nutritional disorders which lead to 
catarrhs. 

The Subjective Symptoms. General. They are often accom- 
panied by extreme distress, but do not lead to a fatal termination. 
The general subjective symptoms are like those of inflammation of 
other mucous membranes. 



THE NOSE AND LARYNX. 419 

1 . Lassitude occurs when there is fever. It is a frequent precursor 
of rhinitis, and is pronounced in croupous and diphtheritic rhinitis ; 
extreme prostration may attend the latter. 

2. Chilliness following the lassitude, or rigor, may occur in the 
same class of cases. If distinct rigors occur, an abscess in one of the 
cavities may be suspected, if the subjective and objective symptoms 
point to it ; or glanders may be present. 

3. Fever. This occurs in the inflammations ; it is never marked, 
and. is not of diagnostic significance. It is most severe in glanders. 
It is then attended by general symptoms of rigor, with pain in the 
trunk and limbs. In the first twenty-four hours there may be nausea 
and vomiting. Locally, a small pimple is seen which is quite painful. 
A yellowish sanious discharge oozes from the nostrils. Hard pustules 
appear about the nose and other parts of the body. (See Infectious 
Diseases.) It is of low type in diphtheria, and of hectic character when 
there is abscess. High fever associated with inflammations of the nose 
points to influenza or one of the exanthemata as the primary cause of 
the rhinitis. Foreign bodies in the nose may cause fever. Emacia- 
tion occurs with malignant growths. 

Local. Pain, varying in degree, occurs in all acute affections of 
the nose. Its seat and character are of some diagnostic significance. 
Smarting or burning pain at the root of the nose accompanies acute 
rhinitis and attends post-nasal catarrh. The pain is diffuse and indefi- 
nite in dry catarrh and in diphtheria. The most severe pain occurs 
when foreign bodies are present in the nose and in cases of glanders 
and primary syphilis. Foreign bodies of a vegetable nature by swell- 
ing and germinating induce pain, Avhich increases gradually in in- 
tensity. 

In tropical regions parasites may be found in the nostrils. They 
are the larvse of the lucilia hominivora. It is said that the pain is so 
severe at the root of the nose, extending backward, as to cause mani- 
acal delirium. Sleeplessness is marked, and there may be extensive 
destruction of the bones and skin. There is a fetid, sanious discharge. 

Pain Over the Frontal Sinus. The pain of an inflamed frontal 
sinus is more severe than the pain of inflamed nostrils. It is some- 
times intense and agonizing. Pain may be located in the cheek from 
inflammation or tumors of the antrum. In disease of the nose, if the 
pain radiates to the ear, the Eustachian tubes are probably involved. 

Headache is frequently caused by nasal disease of all forms. (See 
Chapter IV., Part I.) 

Disturbance of the Sense of Smell. (See the Nerves.) Anosmia and 
Parosmia. Loss of smell, or anosmia, occurs to a moderate degree in 
all the inflammatory and obstructive diseases of the nose. The in- 
tensity depends upon the degree of change in the mucous membrane. 
It may also be due to disease of the nerves or the olfactory centre in 
the brain. Parosmia is the perception of abnormal odors, and may 
be a neurosis or psychical difficulty entirely, and hence purely subjec- 
tive, or there may be inability to distinguish an odor when presented 
to the nostril. All odors may appear the same, or agreeable odors 
may seem to the patient very disagreeable. In addition, the patient 



420 SPECIAL DIAGNOSIS. 

may complain of the perception of an odor in connection with the 
nasal disease with which he is affected. Parosmia is due to an involve- 
ment of the olfactory nerves. 

A sense of dryness is a symptom of which the patient frequently 
complains, particularly in the early stages of acute rhinitis and through- 
out the entire course of dry catarrh, or atrophic rhinitis. 

Obstruction or Stenosis. This sometimes causes the greatest 
discomfort to the patient. There may be simply a sense of stuffiness 
and fulness in the nasal and frontal region, or complete obstruction, 
causing difficulty in breathing. In infants it prevents nursing, and 
should always suggest inherited syphilis. It occurs in all the obstruc- 
tive diseases of the nose and nasopharynx, as acute rhinitis, chronic 
inflammation (except the atrophic form), hyperemia, the hypertro- 
phies, polyps, tumors, deviations of the septum, foreign bodies, and 
adenoid vegetations. 

Deafness is present when the Eustachian tubes are invaded or ob- 
structed from inflammation or stenosis. When associated with anosmia 
it may be of central origin. Tinnitus aurium frequently accompanies 
the deafness. 

Cough. The discharge may pass into the pharynx and the larynx 
and cause cough. (See Chapter on Cough.) It occurs, therefore, in 
the catarrhs and obstructive diseases, and is not diagnostic of any nasal 
condition. When the nostrils are too wide, as in atrophic rhinitis, 
cough may occur because irritating particles are admitted through the 
widened aperture. A so-called reflex cough occurs in hypertrophic 
and post-nasal disease. 

Reflex Neuroses. 

Hay Fever. Hay fever is an acute affection ushered in by paroxysmal 
sneezing, itching, and smarting of the inner canthus of each eye, or of 
the throat or nose. After hours or days of sneezing coryza develops. 
The disease continues for a varying length of time, is more pronounced 
at certain seasons of the year, particularly the late fall. Coughing may 
be an additional symptom, and paroxysms of asthma may develop 
which are hard to distinguish from true bronchial asthma. The attack 
may be excited by vegetable emanations, particularly the pollen of 
plants, but other emanations may also induce it. Certain conditions 
of the nasal mucous membrane predispose to the attack. Local inflamma- 
tion of the nose or obstructive diseases from hypertrophies are primarily 
present. To the exciting cause and the local predisposing cause may 
also be added a neurotic factor. The disease affects families of ner- 
vous constitution, and may occur through several generations. It is 
more common in this country than in other countries, and dwellers in 
cities are more subject to it than residents in the country. Asthma may 
be due to disease of the nose, but the only proof that it is of nasal origin 
is that it disappears after the nose has been treated for the various ail- 
ments that are supposed to cause it. 

Idiopathic Rhinorrhcea. Characterized by a sudden profuse 
disci large of yellowish water. It ceases as suddenly as it develops, and 
is thought to be due to some functional derangement of the fifth nerve. 



THE NOSE AND LARYNX. 421 

The Data Obtained by Observation. 

The Objective Symptoms. Of the general objective symptoms, 
fever has been noted. In certain affections of the nose defective de- 
velopment of the general system is observed. This is particularly the 
case in adenoid vegetations of the nasopharynx in children. (See 
Diseases of the Pharynx.) 

Local Examination. The Exterior. The external appearance 
of the nose is of diagnostic significance when marked deformity takes 
place. Its true shape is changed in myxoedema (q. v.). It is changed 
in disease of the bone due to syphilis. The bridge of the nose is sunken 
or depressed. It must not be confounded with the depression that 
occurs in fracture. The nose may be broadened in cases of tumors of 
an expanding nature in the nasal cavities. The local change soon 
extends to the cheek. The nose is also the seat of eruptions, as acne 
and hyperemia, but they are usually of local origin. They may be 
suggestive of a gouty diathesis. 

Internal Examination. The examination of the cavities of the 
nose consists of two procedures, both of which are necessary to deter- 
mine with accuracy the condition of the organ. These are : 

1. Anterior Rhinoscopy. For this are needed a good light, a nose 
speculum of some form, probes, a 10 per cent, solution of cocaine, and 
a head-mirror with central opening. 

The examiner proceeds as follows : The patient is seated facing the 
surgeon, with the light behind and at one side of the head, as nearly 
as possible on a level with the eye of the operator. He must sit with 
shoulders and head a little forward. The operator adjusts his head- 
mirror so that the central aperture is in front of his own eye, and the 
reflected light falls on the nose of the patient. It is very important 
for nose-examination that the operator look through the aperture and 
not under the mirror. The speculum is then taken in one hand and 
the nostril dilated, so that the view of the interior is unobstructed. 
Do not try to dilate the bony part of the nose, but only the nostril. 
Proceed from before backward with the examination, carefully focus- 
ing the light on each part in succession, and gradually tilting the 
head of the patient backward. Thus the floor of the nose, the septum, 
inferior turbinated bones, middle turbinated bones, and sometimes the 
superior turbinated bones, are brought into view successively. In a 
broad nose one may at times see the posterior wall of the pharynx, 
which is distinguished by its peculiar wave-like movement when the 
patient swallows. The use of the probe is important, and without it 
no positive diagnosis can be made. With the probe the operator tries 
the condition of the mucous membrane, tests the consistency of tumors 
or hypertrophies, and so judges of the character of the condition. After 
this the enlarged parts should be touched with cocaine and the result 
observed. Contraction of a swelling under its influence proves its 
vascular origin. 

2. Posterior Rhinoscopy. This is the most difficult part of the ex- 
amination and requires much practice on the part of the operator. 
The instruments needed are a tongue depressor, head-reflector, two 



422 



SPECIAL DIAGNOSIS. 



sizes of throat-mirrors, a palate-hook or flat strings for holding for- 
ward the soft palate, and a curved applicator for cocaine, or a spray 
bottle with tip turned upward. 

The patient is seated as before, the tongue held down by the tongue- 
depressor, and the patient is told to breathe freely through both mouth 
and nose. The light is directed into the pharynx and a mirror of the 
largest possible size inserted carefully behind the soft palate. The 
proper angle and the movement necessary to bring all parts into view 
can only be learned by practice. As a rule, it is best to hold the 



Fig. 110. 




Rhinoscopic mirror in position. (Boswokth.) 

handle well up at first, and note the condition of the vault of the phar- 
ynx, then gradually depress it, examining the choanal from above 
downward. Do not keep the mirror too long in the throat. It is 
better to insert it several times than to weary the patient by attempting 
to see everything the first time. After the choanse have been exam- 
ined a turn of the mirror to either side will bring into view the orifices 
of the Eustachian tubes, and the examination is complete. If, after 
repeated attempts, it is found to be impossible to see the posterior 
nares, one must first seek to accustom the patient to the presence of 



THE NOSE AND LARYNX. 423 

the instruments ; if this fails, it may be necessary to resort to the 
palate hook or the cords to hold the uvula forward. The best hook is 
White's. It is necessary to apply cocaine to the soft palate before in- 
serting the hook. Another plan, which is preferred by some, is to 
take the flat cords used for corset-laces, soak them in mucilage and dry 
them. These are then stiff enough to pass through the nostril, yet 
flexible enough to pull down and out through the mouth with forceps. 
Then by drawing forward both ends the soft palate is pulled out of 
the way. This is almost always necessary when applications are to be 
made to any spot in the pharynx. 

Sometimes a view of the posterior nares may be obtained by making 
the patient breathe in short, quick gasps, by which the uvula is re- 
leased. In ordinary breathing it is often tightly pressed against the 
posterior wall of the pharynx. 

Fig. 111. 




12 



Rhinoscopic image. 
1. Vomer or nasal septum. 2. Floor of nose. 3. Superior meatus. 4. Middle meatus, 5. Superior 
turbinated bone. 6. Middle turbinated bone. 7. Inferior turbinated bone. 8. Pharyngeal orifice 
of Eustachian tube. 9. Upper portion of Rosenmiiller's groove. 11. Granular tissue at anterior 
portion of vault of pharynx. 12. Posterior surface of velum. (Seiler.) 

By the above methods we are to determine the appearance and nutri- 
tion of the mucous membrane, relative size of the cavities, the nature 
of the discharge, and the presence of ulceration or perforation of the 
nares. Deviations of septum, enlargement or contraction of turbinated 
bones, the size of the cavities, and the presence of foreign bodies or 
abnormal growths are also detected. 

Inspection. Appearance of the Mucous Membrane. The 
observer may find it unusually pale. This is seen in tuberculosis 
and in atrophic rhinitis. If a protuberant mass is observed to be 
transparent and shining, as well as pale, it is due to a polypus. If the 
mucous membrane is bright red, it may be due to acute inflammation, 
to glanders, or to syphilis. It is dull red in chronic catarrhs and caseous 
rhinitis. The coatings of the mucous membrane are of significance. 
If a dry mucus covers the part, it is due to dry catarrh; on the other 
hand, a dirty-gray membrane is indicative of diphtheritic rhinitis. 

It is swollen and bathed with a serous, seropurulent, or purulent 
discharge, the character depending on the stage of inflammation. The 



424 SPECIAL DIAGNOSIS. 

contractile tissue over the turbinated bones is congested and swollen. 
When probed it is elastic, and when cocaine is applied it shrinks. 

In chronic hypertrophic rhinitis the uvula is thickened and elon- 
gated, on account of the hawking. The outer surface or the edges of 
the turbinated bones are enlarged throughout or in localities. The 
mucous membrane covering these spots is thickened, hard, and rough. 
If cocaine is applied, the mucous membrane does not contract, as in 
the swelling due to hyperemia. The posterior ends of the inferior or 
middle turbinated bones are enormously enlarged, forming round 
tumors which obstruct more or less the posterior nares and project into 
the pharynx ; polyps and deviation of the septum complicate these 
cases. 

The same appearances are seen in chronic post-nasal catarrh, and 
in addition a mammillated and thickened appearance of the pharyngeal 
mucous membrane and that of the posterior third of the septum. In 
dry catarrh the mucous membrane is coated with mucus or covered 
with crusts. The membrane is thin, pale, hard to the touch, and cov- 
ered with a layer of dried secretions and crusts in atrophic rhinitis. 
The nasal passages are abnormally wide and one or both turbinated 
bones are atrophied. 

Abnormal Growths. A grayish yellow or greenish shiny mass, with 
a broad base, soft and yielding on probing, is a nasal polypus. It 
cannot usually be circumscribed. The passages are enlarged in atrophic 
rhinitis. One may be occluded by an enlarged turbinated bone or by 
deviation of the septum. 

Ulceration. Ulceration of the mucous membrane is usually a 
manifestation of lupus, tuberculosis, or tertiary syphilis. In lupus the 
ulceration has extended from the exterior. If ozsena is present in a 
patient with lupus it is probable that there is also lupus of the nasal 
passages. The ulcers may be followed by necrosis and caries of the 
bones. If the ozsena is not removable by antiseptic sprays the bones 
are probably affected. A discharge of sequestra makes the diag- 
nosis positive. Rhinoscopy and careful palpation may reveal the ulcer 
and a carious bone. Tuberculous ulcers are usually found in the septum. 
They are rarely primary. They present a whitish-gray surface, with 
elevations of infiltrated tissue. They bleed on the slightest provoca- 
tion. The mucous membrane surrounding them is torn. Tubercle 
bacilli can be found in the scrapings from the ulcer. In syphilis the 
ulcers are situated anywhere in the nares. A history of infection, or 
of secondary and tertiary manifestations, can be obtained. The stench 
of the breath is sickening, and the patient complains of stenosis and 
loss of smell. There is some localized tenderness, and sleeplessness, 
debility, and emaciation may ensue. They may be mere superficial 
excoriations, or deep serpiginous ulcers surrounded by an inflammatory 
zone. Caries can be detected with a probe. The ulcerated surfaces 
are covered with a dry, greenish crust. Foreign bodies usually cause 
ulceration if impacted. 

Neuro-paralytic ulcers are painless and spread rapidly over consider- 
able surface ; they follow paralysis of the fifth nerve. They are dry 
and sluggish and do not extend to the skin. Post-febrile ulcers follow 



THE NOSE AND LARYNX. 425 

measles, scarlatina, typhoid, and variola, and are due to rupture of 
small abscesses, with the subsequent formation of ulcer. They are 
usually anterior on the septum or inside the alee, and scabs form over 
the surface. They are very irritable. Ulcers may perforate the 
septum or the floor of the nose. They are usually due to syphilis. 
Simple perforating ulcer of neuro-paralytic origin may also occur. 

Nasal Secretion. The odor of the discharge is suggestive of 
diphtheria and also of the presence of foreign bodies. The discharge 
in the latter instance is sanious or purulent. Animal parasites, as 
well as pease and beans, cause pain, symptoms of obstruction, and ulcer- 
ation. In syphilis with caries the odor is marked, usually gangrenous. 

Atrophic Rhinitis, or Ozsena. The odor is characteristic, and is 
diagnostic if syphilis is excluded. A sense of dryness is complained 
of. Occasional obstruction arises from accumulation of crusts, other- 
wise the passage is unduly open. There are constant hawking and 
spitting of brownish-green crusts, which are often blood-tinged. Frontal 
headaches may occur in paroxysms. The patient is often depressed in 
spirits. The bridge of the nose may fall in slightly. 

Physical Character. The character of the secretions is of diag- 
nostic significance. They may be liquid, semi-solid, or solid. The 
liquid secretions may be serous, mucous, or purulent. Serous secretions 
occur in acute rhinitis, hay fever, and idiopathic rhinorrhoea, and follow 
bursting of cysts. The secretion of mucus occurs in the later stages 
of inflammation of the mucous membrane and in chronic forms. A 
mucopurulent secretion is seen in chronic rhinitis, and pure pus in 
abscesses of the septum or cavity. In hereditary syphilis it is at first 
mucopurulent, then purulent, and then sanious. A sanious acrid dis- 
charge, with false membrane discharged or evident on inspection, is 
due to diphtheria. A fetid, sanious, or ichorous discharge, with fre- 
quent attacks of epistaxis, attends malignant nasal growths. A dis- 
charge of blood is known as epistaxis. (See page 426.) The semi- 
solid secretions may be due to mucus alone, or to blood-clots mingled 
with serum or with pus. The latter occur in atrophic and hyper- 
trophic catarrhs. 

Caseous Rhinitis. A semi-solid secretion is diagnostic. On exami- 
nation the cavities in this affection are found to be filled with cheesy 
matters, easily broken up with the probe. The mucous membrane is 
dull reel. The material is discharged in masses at intervals through the 
mouth or nostrils, relieving the previous extreme stenosis. If neglected 
for a long time, deformity of the face and disease of the bones and car- 
tilages ensue from pressure. 

The solid secretions may be mucous crusts, as in acute and chronic 
catarrhs, blood-crusts after epistaxis and traumatism, membrane in 
diphtheritic rhinitis, slough from ulcers, and rhinoliths. The latter 
are gray or greenish-brown in color, hard and rough, either fixed or 
movable. 

Microscopical Character. The normal secretion from the nose con- 
tains squamous and ciliated epithelium, isolated leucocytes, and vari- 
ous fungi. The fluid is thick, alkaline in reaction, and has a slight 
odor. It contains mucin. In disease of the nasal cavities the fluid 



426 SPECIAL DIAGNOSIS. 

changes. In acute nasal catarrh it is more copious and thinner. It 
remains alkaline, and contains epithelium and fungi. When the stage 
of suppuration is reached, the secretion may consist entirely of pus. 
Cerebrospinal fluid may also be discharged through the nose in certain 
brain-tumors. In such fluid albumin is absent. Detection of this 
fluid is of diagnostic value, as it points to the central lesion. 

The Charcot-Leyden crystals are found in the nasal secretion in 
asthmatic patients, and sometimes in acute coryza. 

Bacteriological Character. In diphtheria the characteristic micro- 
organism is seen. Recognition of glanders may be based upon finding 
the bacillus in the nasal secretion. (See page 336.) Cultivations 
may be made. The nature of ulcers may be determined by microsco- 
pical examination. The tubercle bacillus can sometimes be detected. 
A pneumococcus or bodies that resemble it have been found in the 
secretion in ozsena. Thrush-fungi have also been found, as well as 
some mould fungi. 

Mouth-breathing. Much valuable information is obtained by 
noting the breathing and the condition of the voice. Mouth-breathing 
may be present if the face is drawn and vacant and there are cracks 
and fissures in the mouth. The voice is usually nasal. The resonating 
quality is lost entirely. Snoring accompanies these conditions. (See 
Obstructive Symptoms.) 

Palpation. The probe is used to determine the character of en- 
largements or tumors, and the patulency of foramina ; also to examine 
the mucous membrane as to induration and the presence of caries or 
necrosis. By the finger the nasal pharynx is palpated to confirm the 
results of rhinoscopy. In this manner adenoid vegetations and hyper- 
trophy of the inferior turbinated bones are detected. The finger should 
be protected by the use of a mouth-gag or by a jointed thimble. 

Epistaxis. The blood may flow in drops, or a continuous stream 
may pour out from the anterior nares. Sometimes it falls into the 
pharynx and is hawked up, or is swallowed and then vomited. 

It may be due to local causes, or to constitutional conditions. Trau- 
matisms (scratching the nose), new growths, and foreign bodies are 
causative agents ; it may be due to fractured skull. Local causes : 
On inspection, the cause may be found in enlarged veins at the anterior 
inferior portion of the septum, a bleeding ulcer, a new growth, or 
the ulceration of a foreign body. The general conditions which are 
causal are : (1) Plethora ; (2) engorgement due to the ascent of an 
elevation ; (3) all forms of anaemia ; (4) hemophilia ; (5) cerebral con- 
gestion and severe headache ; (6) the commencement of fevers, particu- 
larly typhoid fever ; (7) early stages of leprosy. In children exposed 
to the sun, and after exertion, it is of frequent occurrence, and is seen 
often at puberty in delicate children. 

Diseases of the Nose. 

The subjective and objective symptoms previously described are due 
in general to inflammations, malformations, morbid growths, and foreign 
bodies. They are recognized by their subjective and objective signs, 
by rhinoscopic examinations, and by bacteriological and microscopical 



THE NOSE AND LARYNX. 



427 



research. The inflammations may be acute or chronic, primary or 
secondary. When secondary, both acute and chronic inflammations 
may be due to infections. To the acute varieties belong the acute 
catarrh of measles, glanders, hay fever or influenza ; to the chronic 
belong syphilis and tuberculosis. 

Simple Acute Rhinitis. Acute Coryza, " Cold in the Head." 
Ushered in with a feeling of lassitude, aching in the back and limbs, 
and feverishness, a sense of fulness is felt in the nostrils, with sneezing. 
After twenty -four hours an irritating discharge begins. During this 
time the malaise has increased. The pain in the forehead and cheeks 
has become more pronounced, and a nasal twang is given to the voice. 
The feverishness continues, reaching 101° in the more pronounced 

Fig. 112. 




Vertical section through nasal cavities. (Diagrammatic.) (Seiler.) 
1. Superior turbinated bone. 2. Middle turbinated bone, with posterior hypertrophy, 
of hypertrophied pharyngeal tonsil. 4. Inferior turbinated bone. 5 



Section 
Orifice of Eustachian tube. 



cases, with thirst and loss of appetite. At the height of the fever, in 
twenty-four or forty-eight hours, a crop of herpes very often develops 
on the lips. The general symptoms then subside and the local symp- 
toms change. The discharge becomes thick and purulent, the fulness 
continues, but the pain is diminished. The inflammation often extends 
up to the tear-ducts and to the eyelids. The latter are congested and 
smart very much. Very frequently, also, the inflammation extends 
to the pharynx, causing soreness of the throat and stiffness of the neck, 
and the larynx even may be involved. A slight deafness may result 
from the inflammation extendi og into the Eustachian tube. 

Chronic Rhinitis. Four varieties are distinguished, to all of which 
the term nasal catarrh is applied. In one there is hypertrophy of the 



428 



SPECIAL DIAGNOSIS. 



turbinated bones ; in the second there is extension of the disease to the 
post-pharynx — chronic post-nasal catarrh ; in the third there is abso- 
lute dryness of the mucous membrane — rhinitis sicca, or dry catarrh ; 
in the fourth there is atrophy of the mucous membrane — atrophic 
rhinitis, or ozama. 

Chronic Hypertrophic Rhinitis. The affection comes on gradually 
after repeated acute attacks of coryza. The only symptoms may be 



Fig. 113. 




Dilated nostril, showing anterior hypertrophy. (Seller.) 



slight fulness in the nose and a little hoarseness of the voice. In more 
advanced stages the symptoms of stenosis are marked with oral breath- 
ing, snoring, and nasal sound. There is a constant discharge of muco- 
pus backward into the pharynx, causing hawking. The hearing is 
frequently impaired, as well as the taste and smell. The discharge 

Fig. 114. 




Rhinoscopic image from a case of posterior hypertrophy on the middle turbinated bone. (Seiler.) 

often affects the larynx, causing an irritating cough. The hypertro- 
phied tissue on the turbinated bones, and the pressure of the bone on 
the septum, may lead to reflex attacks of asthma. 

Chronic Post-nasal Catarrh is an extension of the rhinitis into the 
pharynx. It is distinguished by discomfort or pain in the soft palate 
and posterior nares. There are tingling and a sense of fulness at the 
root of the nose, with frontal headache ; the patient complains of a 



THE NOSE AND LARYNX. 429 

bad taste in the back of the mouth and of constant flow of thick secre- 
tion into the pharynx, causing snoring and hawking. The same per- 
version of the senses of taste, smell, hearing, and of the voice occurs 
as in acute rhinitis. Headache seems to be due to the condition of 
the pharynx. (See Atrophic Rhinitis, page 425.) 

Dry Catarrh, or Rhinitis Sicca, is also chronic in its course, accom- 
panied by tingling and dryness of the nostrils. A faint, musty odor 
is detected, but there is no discharge or sense of obstruction. In severe 
cases there may be sharp pain in the nose extending to the forehead. 

Syphilitic Coryza is seen in infants and young children affected 
with hereditary syphilis. The nostrils are swollen and red at the 
edges, sometimes completely occluded, causing oral respiration and 
inability to take the breast or bottle. 

Pustules, fissures, and ulcers are found in the nose and at the margin 
of the orifices. They are also seen in the pharynx and larynx. Hem- 
orrhages may occur. Other evidences of hereditary syphilis are present. 

The Auxiliary Cavities of the Nose. 

The Antrum is subject to abscess, cysts and polypi, parasites, and 
tumors. 

Abscess. An odor somewhat like that of ozsena, a putrid taste, 
nausea, anorexia, pain in the cheek and root of the nose, often neural- 
gia in the frontal region, and malaise are present. A very character- 
istic symptom is the discharge of pus from one nostril on leaning the 
head forward. There is often a bad tooth on the same side in the 
upper jaw. 

The Sinuses. The frontal, ethmoidal, and sphenoidal sinuses are 
subject to inflammation, abscess, traumatism, and the irritation of 
foreign bodies, usually parasites. 

The frontal sinuses are the only ones which exhibit external symp- 
toms. When these cavities are inflamed the patient complains of pain 
and tenderness over the frontal protuberances ; if the process goes on 
to the formation of abscess, there may be redness and swelling and 
finally fluctuation. If the communication is not closed, there is a 
fetid discharge from the middle meatus. 

When the sphenoidal and ethmoidal sinuses are affected there are no 
external symptoms unless the enlargement is so great as to affect the 
orbit. There is deep-seated pain. Pus is seen exuding into the supe- 
rior meatus and flowing backward into the pharynx. Parasites cause 
intense pain and lead to abscess, caries, and necrosis. RMnoscopic 
examination in disease of the antrum shows rough hypertrophic en- 
largement on the under surface of the middle turbinated bone and a 
flow of pus into the middle meatus. Sometimes a probe can be passed 
into the antrum from the nose. Often an exploratory puncture is 
necessary. When the foramen is obstructed there is a dull aching pain 
in the upper jaw, with deformity of the orbit, face, hard palate, and 
nostril. Fluctuation can usually be found at some point after a time. 

The laerymal duet and sac are often the seat of inflammation by ex- 
tension, causing pain, obstruction in the nose, and epiphora. On 



430 SPECIAL DIAGNOSIS. 

examination pus will be seen flowing forward over the inferior meatus. 
When the lacrymal probe is introduced the ducts are found to be 
painful and obstructed, and pus exudes. 

The Larynx. 

The structural composition of the larynx does not differ from that 
of other parts of the respiratory passage. Mucous membrane, connec- 
tive tissue, cartilages, and muscle are similar to the same tissues situ- 
ated elsewhere. 

The result of their anatomical association in the larynx is the estab- 
lishment of the functions of that organ, the formation of the voice and 
the admission of air. Now, the morbid processes that affect the larynx 
do not differ from morbid processes elsewhere in which similar tissues 
are involved. Each tissue is liable to congestion, to inflammation, to 
degeneration, to new-growth formation ; the joints may become anky- 
losed, the muscles either paralyzed or the seat of spasm, and we have, 
therefore, all the symptoms common to morbid processes in each class 
of tissue. We meet with other symptoms beside, which result from 
the anatomical position of the larynx and of its functions. The cords 
cannot vibrate, or the muscles and articulations cannot move, and dys- 
phonia or aphonia occurs. The narrow chink of the glottis soon be- 
comes occluded, giving rise to dyspnoea. Obstruction to the pathway 
or pain from inflammation or ulceration causes dysphagia. The sensi- 
tiveness of the mucous membrane provokes cough on the slightest 
provocation. 

The larynx is a highly specialized organ, and is well innervated. 
Large central nuclei, connected by a large nerve which passes over a 
circuitous route and which anastomoses with other nerve-cords, preside 
over the function of phonation. Affections of the central nuclei, affec- 
tions of the nerve-trunk or of adjacent structures exerting pressure 
upon the trunk, have their expression in disorder of the larynx, par- 
ticularly if phonation is disturbed. In other words, the phenomena 
of laryngeal disease may be symptomatic of affections of the brain or 
of the nerve-trunk, as well as of the larynx. (See Nervous Diseases.) 

Owing to the anatomical position and special function of the organ 
the symptoms of disease of the larynx are very striking, pointing at 
once to the seat of trouble. Laryngeal affections are not likely to be 
mistaken for disease of contiguous parts, although retropharyngeal 
abscess, abscess at the side of the pharynx, disease of the thyroid gland, 
and inflammation of the lymphatics or cellular tissue in the neck may 
cause symptoms suggestive of laryngeal disease. 

Finally, morbid processes in the larynx determined by the symp- 
toms and physical appearances may be symptomatic of general processes : 
acute inflammation, of erysipelas, typhoid fever, smallpox, or measles ; 
chronic inflammation or ulceration, of the rheumatic or gouty diathesis, 
syphilis or tuberculosis ; scars, of syphilis ; ankylosis, of rheumatic 
gout. The laryngeal symptoms of brain disease or of affections of the 
nerve-trunk have been referred to. 

The practical point of all this is that affections of the larynx are not. 



THE NOSE AND LARYNX. 431 

due to primary disease of that organ alone, but are often secondary 
either to general processes or to local morbid processes elsewhere. 

Therefore, when laryngeal symptoms or lesions are observed, seek 
beyond the larynx, as well as in it, for their cause. 

The Data Obtained by Inquiry. 

The Social History. Acute laryngeal diseases are more common 
in childhood, chronic diseases in late life. Those occupations which 
compel the inhalation of noxious vapors or excessive use of the voice 
predispose to laryngeal diseases. Alcoholic subjects and those who 
use tobacco to excess are liable to laryngeal affections. As with the 
nose so with the larynx, no special disease is inherited and need be 
looked for in the family history. But we may inquire for a diathetic 
condition, as gout or rheumatism, which predisposes to a mucous mem- 
brane inflammation, or a family type which leads a parent to say his 
child ' ' has a tendency to croup," a popular expression which has in it 
an element of truth. That condition or state which predisposes to 
" colds " belongs also to a family type. 

On inquiry as to previous disease various acute infections and syph- 
ilis and tuberculosis are to be looked for. In a study of the present 
disease it must be borne in mind that laryngeal affections notably may 
be secondary, and, therefore, the presence of other diseases must be 
inquired into. Particularly do we inquire for nervous diseases, and in 
children for rhachitis. One thing is to be borne in mind — one attack 
of acute laryngitis predisposes to subsequent attacks. 

Subjective Symptoms. Pain. Pain in the larynx may be sharp, 
stabbing in character, or simply a tickling or burning with a feeling 
of pressure. It is increased by pressure and by speaking or swallow- 
ing. Pain is sometimes so intense as to render speaking and swallow- 
ing impossible. In acute laryngitis the pain is cutting and burning. 
In the milder inflammations, in dry catarrh, and in lupus it amounts 
to soreness only. The pain is severe and sharp in cases of cancer and 
tuberculosis, rarely in syphilis, and when foreign bodies are present in 
the structures. The pain may be very severe and intense when there 
is destructive ulceration. It is a diagnostic symptom of perichondritis. 

Perichondritis. Inflammation about the cartilages or perichondritis 
is usually phlegmonous in character, and leads to the formation of 
abscess. The collateral oedema is so great as to cause some obstruction, 
with cough and hoarseness. On palpation the larynx is extremely 
tender. The pain is increased by movement of the larynx, as in speak- 
ing or swallowing. If the inflammation involves the arytenoid carti- 
lages, pain extends toward the ear, the vestibule is swollen, the car- 
tilage fixed. On the other hand, when the cricoid is diseased there 
are pain on swallowing of solid food, on account of interference with 
the muscular attachments, dyspnoea, and paralysis of the posterior 
crico-arytenoid muscles. 

Inflammation of the thyroid cartilage may open externally or inter- 
nally. In the latter case the abscess can be seen in the larynx. Dis- 
charge of pus and necrosed cartilage confirms the diagnosis. By means 



432 SPECIAL DIAGNOSIS. 

of a sound the bare cartilage can be detected, giving further proof of 
the presence of the disease. The pain may extend to the ears in carci- 
noma. The pain is propagated by the auricular branches of the vagus. 

Paresthesia. Peculiar sensations are frequently complained of. 
They may be burning, tickling, or itching in character, or it may seem 
as if a foreign body were present in the part, as a hair, or it may seem 
like a draught of cold air striking the parts. Sometimes after a foreign 
body has actually been present, the sensation of its presence will con- 
tinue a long while after its removal. A sense of pressure or fulness, 
the feeling of a lump in the throat, is frequently complained of, pro- 
voking a desire to swallow. The patient will seek advice on account 
of it. It is known as the globus hystericus, and is recognized by the 
absence of local changes in the larynx, by its association with other 
phenomena of hysteria, and by its disappearance or aggravation under 
the influence of excitement. This abnormal sensation is seen in hys- 
teria and hypochondriasis. It is one of the nerve-perturbations in 
chlorosis and anaemia. 

A feeling of dryness is frequently complained of, and attends the 
first stage of acute, and any stage of chronic laryngitis. The sense of 
fulness, or pressure, or feeling of the presence of a foreign body is com- 
plained of in all forms of laryngitis, in croup, in oedema of the glottis, 
or epiglottis, and in syphilitic infiltration. 

Hyperesthesia and Anesthesia. When there is hyperesthesia 
there is constant desire to cough (see page 435), and the act is induced 
by the slightest irritation. The desire to cough, independently of the 
act, however, is of itself an extreme annoyance. It is a disagreeable 
sensation present in acute inflammations and in early phthisis. At 
times of menstruation and during pregnancy both symptoms are fre- 
quently complained of. Hyperesthesia is easily recognized with the 
probe. In ancesthesia particles of food fall into the larynx. The 
mucous membrane is insensitive to the contact of the probe. Anaesthe- 
sia occurs in hysteria, diphtheritic paralysis, paralysis of the superior 
laryngeal nerve, bulbar paralysis and cerebral softening or hemor- 
rhage, or coma from any cause. 

Dysphoria. The most common symptom of affections of the 
larynx is disturbance of the function of speech. The voice is changed 
in character, or may be lost in any affection which causes swelling of 
the mucous membrane, or occlusion of the orifice, or which interferes 
with the action of the vocal cords. The voice may be hoarse in acute 
and chronic inflammations, in tumors and in specific ulcerations about 
the larynx, and in paralysis of the cords. From simple hoarseness it 
may vary in intensity to complete aphonia. Laryngoscopic examina- 
tion is necessary in order to detect the presence or absence of paralyses. 
(See Paralyses.) 

Chronic Laryngitis. Chronic hoarseness may be due to chronic 
laryngitis. This affection either originates in an acute attack or comes 
on slowly. Prolonged use of the voice in a higher key than natural, 
or in the open air, the use of alcohol, constant exposure, are exciting 
causes. It is symptomatic of syphilis and tuberculosis. It frequently 
results from inflammation of the upper air-passages, particularly chronic 



THE NOSE AND LARYNX. 433 

pharyngitis. It occurs after middle life more frequently, and usually 
in the male sex. There is discomfort on long speaking, with dryness 
and tickling. At first the secretion of mucus is very slight, but after 
hawking and coughing it increases in amount. Hoarseness occurs, and 
if the patient is careless or persists in the baneful occupation, complete 
aphonia may result. The voice is clearest in the morning, after expec- 
toration of the mucus that accumulated in the night, but becomes husky 
toward night. The aphonia may occur in paroxysms, and is relieved 
by coughing up a dry secretion. The cough is never severe. The 
sputum is small in amount, glairy, and is often in little balls or crusts. 

Lupus. Slight hoarseness, deepening to dysphonia or even aphonia, 
attended by soreness, and later some dysphagia, is seen in lupus. In- 
filtration and scar-contractions cause dyspnoea later in some instances. 
Dysphonia from inflammation or oedema is also a symptom of leprosy, 
which, however, is present in other situations as well. The duration 
may be significant. Hoarseness of long duration (years) is said to be 
prodromal of cancer (Ziemssen). 

Functional Dysphonia or aphonia may occur after excessive use 
of the voice and in hysteria. Hysterical aphonia occurs in women 
and young girls ; the laryngoscope reveals nothing ; the acts of cough- 
ing, laughing, and sneezing are normal, and a sound may be created 
in either act ; it appears and disappears suddenly. 

Tone of the Voice. The character of the voice may change. 
When one-sided paralysis of a cord is present the voice is flat and 
toneless. In cases of paresis of the tensors of the cords a falsetto voice 
results. Diplophonia occurs in one-sided paralysis, and in some cases 
in which small tumors lying between the cords come up during the 
act of phonation and form nodes. Two tones are formed at the same 
time. Frequently only certain tones are doubled. 

Dyspnoea. This is one of the frequent symptoms — and the most 
serious — of laryngeal disease. It may be due (1) to obstruction by 
inflammatory or oedematous swelling ; (2) to spasm ; (3) to tumors or 
foreign bodies in the larynx ; (4) to the cicatrization of ulcers after 
syphilis or lupus ; (5) to paralysis of the abductors or adductors of the 
larynx. It may be, therefore, organic or spasmodic. 

Duration. Dyspnoea from disease of the larynx may develop grad- 
ually and continue over a long period of time, or it may be acute in 
onset, depending upon the character of the morbid process which has 
brought about the obstruction, Acute paroxysms of dyspnoea, one of 
which may end in death, sometimes occur in the course of affections in 
which chronic dyspnoea is present ; thus sudden oedema may occur in 
cases of syphilitic or tuberculous ulceration. 

Laryngeal Dyspnoea must be distinguished from other forms of 
dyspnoea : 1. Dyspnoea from diseases of the heart and lungs. 2. 
Dyspnoea from pressure upon the trachea. The larynx is not markedly 
moved during the respiratory acts, and the patient bends the head for- 
ward instead of backward. 3. Dyspnoea from pressure on the larynx. 
Cellulitis of the neck, tumors of the lymph-glands, goitre, and retro- 
pharyngeal abscess are provocative of this form of laryngeal dyspnoea. 
Examination of the respective localities by inspection and by touch 

28 



434 SPECIAL DIAGNOSIS. 

reveals the cause. It may be worthy of remark that dyspnoea in 
diphtheria, frequently thought to be due to internal occlusion, may be 
due to pressure of enlarged glands on the bronchus and larynx. 

Inspiratory Dyspnoea. Dyspnoea may vary in degree from slight 
inconvenience in breathing, noticeable to the patient, to the violent 
struggling for breath which is seen in cases of extreme stenosis of the 
larynx. If carefully observed in either case the larynx is seen to rise 
and fall. In extreme forms of obstruction the head is bent back, the 
neck stretched, the muscles of the neck contracted. The spaces above 
the sternum and at the sides of the trachea are drawn in with inspira- 
tion, and the alse of the nose work vigorously. Further evidence that 
sufficient air does not enter the lungs is found in recession of the epi- 
gastrium and drawing in of the ribs at the base of the chest during 
the act of inspiration. The countenance is dusky or ashy-gray, the lips 
become cyanosed, and the nails bluish as the dyspnoea persists and 
increases. A cold perspiration breaks out on the forehead, and finally, 
from exhaustion, the respiration becomes slower and slower until mere 
gasps are seen. The heart's action increases in frequency as the ste- 
nosis increases. Death usually takes place from asphyxia, the child 
first falling into a stupor, on account of carbonic-acid-poisoning. 

Sounds attend the act of inspiration, the character depending on the 
nature of the obstruction. In obstruction from simple spasm, or from 
intense inflammation of the larynx, without secretion, the sound of 
inspiration is harsh and stridulous. In obstruction from oedema or 
from exudation, as in laryngeal diphtheria, the sound of the inspiration 
is loud and stridulous, but not shrill. The expiration is usually noise- 
less and prolonged. The short, stridulous, or gasping inspiration is 
followed by prolonged gentle expiration. In spasmodic croup the 
expiration is like snoring. The interval between expiration and inspi- 
ration is lessened, the respirations are hurried. 

Laryngismus Stridulus. In this form of dyspnoea the act of 
breathing ceases in the midst of inspiration, and is attended by a 
characteristic sound. It is seen usually in poorly nourished children. 
It is of frequent occurrence in rickets, its presence suggesting that 
disease when other manifestations of it are obscure. 

The symptoms occur suddenly and are very alarming. The child 
awakes in the night, and suddenly stops breathing after a few short 
whistling inspirations. The child is seized with terror, which is de- 
picted on the countenance ; the eyes stare ; the face is pallid at first, 
but rapidly becomes livid. The alee nasi are extended, the head is 
thrown back, and the spine arched. A cold perspiration breaks out 
over the forehead. Carpo-pedal spasms may occur and the urine and 
feces be discharged involuntarily. In a few seconds, or, at most, two 
minutes, the child draws two or more deep, noisy inspirations, each 
one lessening in depth and sound, when color returns to the face, the 
cyanosis gradually disappears, and the child becomes tranquil. 

In mild forms the child " catches its breath. " It holds its breath, 
and then makes a noisy inspiration. 

Attacks of laryngismus stridulus are more rare in adults. They 
may occur in hysterical subjects. In the attack there occurs a series 



THE NOSE AND LARYNX. 435 

of long, harsh, whistling or striclulous inspirations, followed by short, 
noisy expirations. Rarely is there complete closure of the glottis. 

In both children and adults general convulsions may occur during 
the attack, or carpo-pedal spasms alone may be seen. Among adults 
the convulsions occur only in hysterical subjects. 

The diagnosis of laryngismus stridulus is based upon the absence of 
laryngeal symptoms prior to the attack, the absence of cough or hoarse- 
ness, and complete disappearance of all laryngeal symptoms when the 
attack subsides. The absence of pain and fever and of laryngoscopic 
signs is noteworthy. This applies, of course, to spasm that occurs in- 
dependently of laryngeal disease. 

Expiratory Dyspncea. In some forms of laryngeal obstruction 
the exit of air is interfered with, as in a movable tumor below the vocal 
cords. We have expiratory dyspnoea. The act of inspiration is com- 
plete, the act of expiration is suddenly checked by the obstruction, on 
account of which the lungs become overfilled with air and an emphy- 
sema develops. 

Dysphagia. Difficulty in swallowing is most marked when destruc- 
tion of tissue in the larynx takes place, or when there is acute inflam- 
mation about the muscles or their attachments ; hence, when ulcers, 
tuberculous or malignant, are present, or perichondritis arises, the 
difficulty is so great as to prevent the taking of food. 

Dysphagia is recognized by pain and by the falling of particles of 
food into the larynx, exciting cough. It must be distinguished from 
the dysphagia of pharyngeal affections by ocular examination, the loca- 
tion of the pain, and the non-association of rheumatism. 

Inflammation of the Epiglottis. When the epiglottis is the seat 
of acute inflammation there is great dysphagia on account of pain, or on 
account of the obstruction. The sensation of a lump in the throat at 
the base of the tongue or the top of the larynx is complained of, and 
there is pain on swallowing. The pain becomes very intense at times. 
Fluids cannot be taken, for the fluid enters the larynx when the patient 
attempts to swallow, because the epiglottis does not protect the glottis. 
The voice is usually clear throughout the attack, and the general symp- 
toms are not marked. 

When the epiglottis is fixed or ulcerated, and in some forms of ulcer- 
ation of the larynx, the food enters the larynx, and hence produces 
dysphagia. 

Mis-swallowing, or " swallowing the wrong way," occurs in all 
conditions in which food is allowed to enter the larynx. Although 
conditions favorable for its occurrence are present, it may not take 
place unless the patient is off his guard during the act of swallowing, 
as when he is laughing. It may then occur even in normal cases. 
It is associated with anaesthesia of the larynx, and occurs in central 
nerve affections which cause that condition. 

Cough. (See Diseases of the Lungs.) Sometimes valuable infor- 
mation is derived from the character and severity of the cough. Sev- 
eral forms are noted : 

First, the dry cough, as seen in acute laryngitis. It is almost con- 
stant, and is aggravated when the patient speaks, takes fluid, or inspires 



436 SPECIAL DIAGNOSIS. 

deeply. In children it is abrupt, brassy, or metallic, stridulous or 
whistling, so-called ' ' croup-cough," as seen in cases of ' ' false croup " 
and laryngitis with oedema. 

Second, a dry hoarse cough occurs in the course of chronic laryngitis. 

Third, cough with whoop. With the act of coughing a whooping 
sound may be heard in inspiration. After rapid violent expiratory 
acts the whoop takes place with inspiration. It is spasmodic and con- 
vulsive, and is followed by retching, and often by vomiting. (See 
Pertussis.) 

Fourth, the cough is of such a character as to give one the idea that 
it is suppressed in membranous and cedematous laryngitis. ; 

Fifth, a cough frequently occurs without any local anatomical changes 
in the larynx, which seems to be purely of nervous origin. Two forms 
are seen : a. Paroxysmal. Severe coughing occurs suddenly, and can- 
not be controlled by the patient. It ceases without cause, returning 
in a few hours. There is no expectoration, b. Continued and rhythmi- 
cal. It is not so severe as in the paroxysmal form, but consists in a 
regularly recurring cough more or less loud. It does not occur while 
eating or speaking and ceases entirely during sleep. It is usually 
worse when the patient is under observation. Examination with the 
laryngoscope reveals absence of disease. This form of cough is seen 
after diphtheria, when sexual disturbances are present, at puberty, in 
cases of anaemia and chlorosis, or of neurasthenia or hysteria. The 
tone is usually high. 

Hemoeehage. Hard coughing or an unusual straining of the 
voice may lead to the occurrence of slight hemorrhage. Only after 
injuries are hemorrhages from the larynx at all copious. Moderate 
hemorrhages occur in scurvy, haemophilia, hemorrhagic smallpox, 
typhus fever, and leukaemia. 

Distuebance of Co-obdination. Several forms of such disturb- 
ance are seen. Spasm of the glottis may occur with each effort to 
speak, causing either serious interference or complete inability to utter 
a word, as in stuttering. Sometimes, instead of the glottis opening to 
complete the act of inspiration, it may close. Sudden inspiratory 
dyspnoea, therefore, occurs, and is attended with stridor. 

Spasm of the glottis is a frequent complication of disease of the 
larynx. It is seen in " crises," as in locomotor ataxia. 

The Data Obtained by Observation. 

Objective Symptoms. The objective symptoms are determined by 
inspection and palpation. Inspection of the exterior of the larynx re- 
veals the presence of swelling, and the movements of the organ as a 
whole. Local swelling of the tissues over the larynx may occur in 
inflammations of the cartilages ; they are usually of syphilitic origin, 
but may attend carcinoma or tumor. There is more or less marked 
swelling in inflammation of the cartilages, which after a time fluctu- 
ates, and, when opened, discharges pus and necrosed cartilage. The 
objective signs of inflammation are noted. 

The movement of the larynx is increased in cases of dyspnoea. It 



THE NOSE AND LARYNX. 



437 



is accompanied by recession of the spaces above the sternum and the 
clavicles, with clonic contraction of the sterno-cleido-mastoid muscle. 

The interior of the larynx is studied by inspection (laryngoscopy), 
and by palpation (probe or fingers). 

Laryngoscopy. The first requisite is a good light, sunlight, a good 
student' s-lamp, or an Argand or Welsbach gas-burner ; the electric 
light is not satisfactory. Second,^ good reflector is required. It may 
be attached to a head-band or a spectacle-frame. It should be concave 
for artificial light, plain for sunlight, and should be pierced in the 
centre. Third, laryngeal mirrors of different sizes and a curved probe 
complete the instruments necessary for examination of the larynx. 



Fig. 115. 




Laryngeal mirror in position, displaying the laryngeal image. (Cohen.) 

Examination. The patient is seated with the source of the light 
at one side and behind him ; the head and shoulders are brought well 
forward and the head slightly raised. The operator takes a seat in 
front at a proper distance for the focal length of the reflector, and 
focuses the light on the patient's mouth, warms the laryngeal mirror 



438 SPECIAL DIAGNOSIS. 

over the flame and tests its temperature on the back of the hand. It 
should be moderately heated, so that when it is placed in the mouth 
the vapor of the breath will not precipitate on its surface. The patient 
must open the mouth and protrude the tongue, which is grasped be- 
tween the folds of a napkin by the thumb and fingers of the operator. 
The tongue should be gently but firmly grasped. The mirror is then 
inserted carefully and quickly, face downward, into the pharynx. 
Care must be taken not to touch the tongue or palate, otherwise the 
patient may be made to retch and become alarmed. The mirror is 
passed to the posterior wall of the pharynx, and so directed that the 
image of the larynx is reflected to the eye of the operator. The patient 
is made to phonate " a " or " ee," not " ah," and then to respire. 
The various structures and the action of the cords are observed. The 
appearances of the mucous membrane are studied during quiet respira- 
tion. 

The epiglottis is very dependent, so that often the larynx can only 
be seen by having the patient stand while the operator remains seated. 
The patient's head is bowed on his chest and the examination proceeds. 

The first examination may not result satisfactorily, but little being 
observed on account of the spasm of the pharyngeal muscles. Re- 
peated sittings may remove apprehension and accustom the mucous 
membrane to the presence of the instrument. This object may be 
attained by administering bromides, or by applying cocaine to the 
pharynx. 

The probe is needed only to ascertain the consistency of tumors and 
growths. Cocaine must be applied before it is used. 

Appearance of the Larynx in Health. Fig. 115 shows the larynx 
as it is seen in the laryngoscopic mirror. Above (upper part) is the 
arched epiglottis, below it the cavity of the larynx. In the centre are 
the vocal cords, white and glistening ; on each side of these the pink 
folds of the false cords. At the bottom of the mirror are the aryte- 
noid bodies, and between them the folds of the inter-arytenoid space. 
Below and outside the arytenoid bodies are the fossae. The mucous 
membrane is pink throughout except on the cords. In respiration 

Fig. 116. Fig. 117. 




Wmmi i k'9ir^ 




Laryngeal image during respiration. Laryngeal image during phonation. 

the arytenoids separate, carrying the ends of the cords which are 
attached to them with them, and leaving a triangular opening — the 
glottis — through which the rings of the trachea can be seen. (See Fig. 
116.) In phonation the arytenoids approach each other, obliterating 
the inter-arytenoid space ; the inner edges of the cords come in con- 
tact and close the glottis. (See Fig. 117.) 



THE NOSE AND LARYNX. 439 

Appearance in Disease. A note must be made of the color of the 
various parts, of the presence or absence of swelling, of ulceration, of 
new growths, and of alterations of the movements of the parts concerned 
in phonation, particularly of the cartilages and the cords. 

Color. The color is an indication of the degree of congestion. 
Ancemia of the larynx may be merely a part of a general anaemia from 
any cause. In chlorosis it is seen before the external appearance is 
marked. An intense anamiia of the larynx is an early and valuable 
symptom of pulmonary tuberculosis. The mucous membrane is pale. 

Hypoxemia may be active or passive. It is readily recognized by 
the intense redness. 

Active hyperemia occurs in acute laryngitis, either of the primary 
or secondary forms. 

Passive hyperemia occurs in general obstruction to the circulation, 
as emphysema or valvular lesions ; pressure on veins by tumors ; 
forced expiration and holding the breath ; hi paroxysmal cough, espe- 
cially whooping-cough. Active hyperemias lead to catarrhs, passive 
to oedema. 

Swelling and Infiltration. Swelling of the epiglottis and of the 
aryteno-epiglottidian folds is seen in oedematous laryngitis, in acute, 
submucous, and chronic laryngitis. In oedema of the glottis the swell- 
ing is below the vocal cords. The swelling may be circumscribed 
and undergo suppuration. Swelling and oedema is also seen in peri- 
chondritis. 

Tuberculosis. Swelling and infiltration succeeds the primary 
ansemia or catarrh of the first stage of laryngeal tuberculosis. At first 
there is slight intumescences of tubercular infiltration, not well out- 
lined, and gray in color. They are most frequently found in the inter- 
arytenoid space, less often on the false cords and arytenoid cartilages, 
rarely on the epiglottis. 

1. A hill-like prominence between the arytenoid cartilages either in 
the middle or on one side. In phonation it presses between the cords. 

2. When a false cord is affected the whole of it is usually infiltrated, 
forming a tumor-like sAyelling which often hides the vocal cords. 

3. Vocal cords. Usually only one cord is at first affected. It is 
thickened and the free border is red. Sometimes the free edge seems 
split. The infiltration may extend to the subcordal region and cause 
a hypoglottic laryngitis. 

' 4. Epiglottis. Infiltration of the epiglottis is rarer than oedema 
after ulceration, and care must be taken not to confound these condi- 
tions. The whole epiglottis, or only portions of it, may be affected. 
It is thickened and curled upon itself, and not freely movable. 

5. Arytenoid cartilages. They appear enlarged and puffy, and often 
fixed from perichondritis. 

Syphilis. In syphilis w T e have three forms of swelling : 
1. Mucous Patches. These are flat elevations of 3 to 7 mm. diam- 
eter, oval or circular, and of a whitish-gray color. When the epithe- 
lium is lost they appear yellow and purulent. There is no tendency 
to ulceration, and the patches soon disappear, even without treatment. 
They occur usually from three to nine months after the infection. 



440 SPECIAL DIAGNOSIS. 

2. Infiltrations. Usually these are overlooked, as they produce no 
symptoms. They are diffuse thickenings in various parts of the larynx, 
most often on the epiglottis. This may be uniformly thickened or 
only in part around the edge. The cords may be so swollen as to cause 
dyspnoea. Usually an ulcerated spot is seen in the centre of the infil- 
tration. The mucous membrane is either normal or reddened. Infil- 
trations appear three to four or more years after infection. 

3. Gummata. They appear as round prominences of the same color 
as the surrounding tissue. They occur on either side of the epiglottis, 
on the ary teno-epiglottic folds, often in the inter-arytenoid space, on 
the false cords, and on the under surface of the vocal cords. If they 
break down, deep ulcers form, leading to extensive destruction of the 
parts. 

Lupus. In lupus isolated or grouped nodes are seen flowing to- 
gether into patches, situated on the epiglottis. The disease is usually 
present on the face or in the pharynx and mouth. In leprosy the 
epiglottis is swollen, and nodes from the size of a pin-head to that of 
a pea are seen on the epiglottis, arytenoid bodies, and false cords. 

Fissures. Fissures and erosions are present in chronic laryngitis. 

Ulcers. Ulceration is seen in tuberculosis, syphilis, carcinoma, lep- 
rosy, and lupus. 

Tuberculosis. Ulceration occurs in tuberculosis in the — 

1. Inter-arytenoid space. The mucous membranes are notched with 
irregular projections. When the ulcer is visible it is irregular and of 
a dirty-gray color. 

2. False cords. The ulcers are flat and aphthous, with a pale-white 
base and a membranous deposit. The mucous membrane sometimes 
appears sieve-like. 

3. Aryteno-epiglottic ligaments. The ulcers are superficial and run 
lengthwise of the ligament. 

4. Vocal cords. The ulcers are either on the upper surface or on 
the edge of the cords. The former are superficial and seldom destruc- 
tive. Those on the edge are either small separate ulcers or long ones, 
affecting the whole border. The circumscribed ulcers occur usually 
at the posterior portion of the cord and on the processus vocalis. The 
ulcers of the whole border are often very destructive. 

5. Epiglottis. Tubercular ulcers of the epiglottis occur only on its 
laryngeal side. They are either aphthous and superficial, or deep, and 
arise from the breaking down of previous infiltration. Sometimes 
tubercles can be seen at the edge of the ulcers, but they are of no diag- 
nostic value, as similar nodes are seen with non-tubercular ulcers. The 
epiglottis is usually thickened and oedematous. 

Syphilis. Syphilitic ulcers are circular, deep, with a sharp border 
and inflammatory areola, and overlaid with a whitish-yellow deposit. 
They develop from an infiltration or a gumma, and not on an unchanged 
surface. Ulcers on the upper surface of the epiglottis are always 
syphilitic. 

Tumors Papilloma. The most common form of the benign 
growth- is the papilloma. The growth may spring from the true or 
false cords, the aryteno-epiglottic ligaments, rarely the posterior surface 



THE NOSE AND LARYNX. 441 

of the epiglottis. The tumor has a broad base. There may only be 
one, or it may be multiple, and may vary in size from a split pea to a 
walnut. Three varieties are met with : 1. Small warty growths, 
usually on the cords, dark red in color, and seldom larger than a bean. 
2. Groups of raised white papilla? on a broad base, also growing on the 
cords. 3. Large, red, mulberry-shaped or caulifloAver-shaped growths, 
partly villous, partly warty, which fill up the whole larynx. 

Fibroma. It appears as a hemispherical, pedunculated tumor of 
dirty-white, reddish, or dark-red color, more or less dense in consist- 
ency. It is usually single, and grows most frequently from the cords. 
When seen in its smallest size it is known as the " singer's node. 7 ' It 
may be as large as a hazel-nut. 

Malignant Tumors. In addition to the symptoms indicated in 
benign tumor, pain and hemorrhage occur. Both carcinoma and sar- 
coma are found ; the latter is very rare. 

Carcinoma. The most common form is the epithelioma, although 
the medullary and scirrhus have been described. The epithelioma is 
seen as a circumscribed, hemispherical, warty, or cauliflower-like forma- 
tion, varying in size, or as a knotty infiltration projecting into the 
larynx. The medullary form is larger, soft and bloody, and rapidly 
ulcerates. Scirrhus is firm and hard. The structure of the larynx is 
gradually invaded, with necroses of the tissues. Perichondritis and 
abscess frequently ensue. 

In carcinoma of the cords two kinds of growth are seen. 

In the polypoid form the tumor develops on the cord like a warty 
growth, sometimes papillary and of a reddish-gray color. In diffused 
cancer of the cord the structures are red and knotty, and invade the 
surrounding tissue without distinct demarcation. 

Sarcoma. The tumor has a broad base, is shining in appearance, 
and sometimes lobulated. Sometimes the structure is dark red or 
yellow. 

The Epiglottis. The epiglottis is swollen and red in inflammation 
of that structure, and may then be palpated with the finger. 

Sputum. The sputum from the larynx is generally scanty ; it is 
not frothy, and is colorless and transparent ; it is often discharged in 
small globules ; it may be streaked with blood. Sometimes pseudo- 
membranes are coughed up. It is doubtful if purulent sputum ever 
comes from the larynx, excepting in cases of perichondritis in which 
the abscess bursts into the larynx. Laryngeal sputum is found in 
catarrh and malignant tumors. It is blood-streaked when the catarrh 
is very intense, or after injuries. 

Fever. Fever is present in acute laryngitis and tuberculous ulcer- 
ation. It is high in acute laryngitis with stenosis ; in tuberculosis it 
is of a hectic type. 

Acute Laryngitis. 

Acute laryngitis is an inflammation of the larynx, characterized by 
a sensation of fulness and dryness, with cough, hoarseness, and at times 
dyspnoea. Several varieties are observed : Simple acute laryngitis, 



442 SPECIAL DIAGNOSIS. 

laryngitis with great stenosis, laryngitis with membrane, laryngitis with 
spasm. 

It is caused by exposure to cold or by the inhalation of acrid vapors. 
Overstrain, as in singers, excessive use of the voice, particularly in the 
cold air, may excite an attack. It may be symptomatic of the erup- 
tive fevers, as measles or smallpox, or erysipelas. Its occurrence in 
the course of chronic diseases must be looked upon with alarm, partic- 
ularly in cases of Bright' s disease, if dropsy is present in other situations. 

The attack begins with a feeling of chilliness, followed by fever of 
varying degree, but usually mild. The patient complains of a feeling 
of pressure and dryness in the larynx, or as if a foreign body were 
present. Some pain gradually develops in the height of the attack, 
never so severe as to require an anodyne. From the first there is 
cough. It is dry and hacking, and slightly painful. In the more 
intense forms the cough is continuous, disturbing the patient night and 
day. Paroxysms occur when the patient speaks or takes food. First 
the cough is dry ; within a short time it becomes moist, and expecto- 
ration of clear, transparent mucus takes place. The mucus may be 
tinged with blood. At the end of forty-eight hours expectoration be- 
comes more yellowish and opaque. The voice may be merely hoarse, 
or may be lost entirely. Sometimes aphonia without general symp- 
toms occurs in acute laryngitis. In laryngitis sicca cough and dyspnoea 
occur in paroxysms and are not relieved until a dry secretion is coughed 
up. The paroxysms take place at night or in the early morning, and 
may cause retching and vomiting. It is seen in adults. 

Acute Laryngitis with Stenosis No doubt some of the cases of 
so-called membranous croup in children are cases of acute laryngitis, 
with swelling and occlusion of the glottis by congestion and by tough 
secretion. OEdema may or may not be present. The attack begins 
with catarrhal symptoms. The child is languid, refuses to eat, is 
thirsty and has some chilliness and rise of temperature. With the 
slight cough, which may be shrill, there are hoarseness and some 
difficulty in breathing, but no pain on swallowing. On the second 
day, or after the lapse of four or five days, during which time mild 
fever continues, the catarrhal symptoms become more marked. The 
voice is more hoarse or may be suppressed. The harsh, clanging 
cough becomes toneless, and soon the sound is suppressed. Dyspnoea 
is most severe, and the aspirations are hurried and noisy, attended by 
loud whistling inspiration, and snoring expiration. The stenosis is 
inspiratory, and during the day or in the succeeding twenty-four hours 
may become very intense. It is attended with violent efforts at breath- 
ing and the occurrence of cyanosis in its most aggravated form. The 
larynx moves up and down, the head is thrown back. TJiere is reces- 
sion at the root of the neck and along the margins of the ribs and the 
epigastrium. The lower portion of the sternum may be drawn in. 
Duskiness of the extremities and of the lips is observed as the stenosis 
becomes more marked, finally deepening into cyanosis. It may be 
relieved from time to time by removal of the obstruction, which occurs 
after cough, vomiting, or change of position. A paroxysm soon recurs. 
With each paroxysm lividity becomes more and more marked, the res- 



THE NOSE AND LARYNX. 443 

pirations continued hurried. The face becomes pale, the extremities 
cold, and a cold sweat bathes the brow. Restlessness is characteristic. 
The child tosses about in the bed or from the bed 10 the arms of the 
nurse. The heart's action is increased each hour in frequency as the 
stenosis advances, and becomes weaker. As exhaustion ensues and 
the symptoms of obstruction become more marked, stupor deepening 
into unconsciousness develops. Convulsions may occur at the end. 
The attacks rarely recur if the patient once recovers. They follow 
exposure to cold. 

If recovery takes place, the child usually becomes more free from 
dyspnoea, the cyanosis fades, and the restlessness disappears. A pro- 
longed sleep follows relief, although the voice may remain hoarse or 
suppressed, and the cough continue many days. 

Laryngeal Diphtheria. The same symptoms are seen in mem- 
branous croup and laryngeal diphtheria. In the latter affection there 
may be a history of exposure or of infection. At the commencement 
of the attack the diphtheritic patches may be seen in the fauces or 
nares. If a membrane can be secured and a bacteriological examina- 
tion made, the diagnosis of diphtheria with stenosis is positive. En- 
larged glands in the neck, with marked physical depression, a mod- 
erate degree or entire absence of fever, and the occurrence of early 
albuminuria, also point to diphtheria. The distinction between the 
two affections is nevertheless quite difficult, and as long as there is a 
shadow of doubt, for prophylactic reasons the case should be consid- 
ered one of diphtheria. 

Acute Laryngitis, with Spasm. False Croup or Spasmodic 
Laryngitis. In children, in addition, another form of laryngitis asso- 
ciated with spasm of the larynx is seen. The catarrhal symptoms 
are mild, so that the child seems to be well during the day. Fever 
is absent, and a slight cough or huskiness alone calls attention to the 
larynx. After the first three or four hours of quiet sleep the child 
suddenly awakes with a barking cough, sits up and struggles for breath. 
The dyspnoea continues from a few minutes to an hour or so, gradually 
lessening, to disappear entirely as the child lapses into sleep. Through- 
out the next day the child seems as well as on the previous day, and 
the succeeding night is again seized with another attack of " croup. " 
This may occur once or twice during the night. It seems to be influ- 
enced by the weather. Damp days and an east wind are provocative 
of an attack. It recurs frequently during the same season. 

(Edema of the Larynx. 

This condition arises in the course of acute laryngitis ; frequently 
occurs in chronic diseases of the larynx, particularly if ulceration is 
present ; and as a complication of erysipelas and diphtheria. In some 
cases of Bright' s disease it may develop suddenly. 

In the course of the above-mentioned disease symptoms of laryngeal 
stenosis may occur suddenly. The voice becomes husky and sup- 
pressed, the dyspnoea is very extreme, so that in a few hours grave 
symptoms of obstruction arise. There is no cough. The patient com- 
plains of the sensation of a foreign body, and tries to grasp it. 



444 



SPECIAL DIAGNOSIS. 



The Diagnosis of Acute Diseases of the Larynx. 

Acute affections of the larynx are distinguished from other diseases 
without much difficulty. To recognize the various forms of acute 
laryngitis, however, is not easy. In all there is laryngeal stenosis to 
a certain degree, and practically the question to answer is, Which form 
of stenosis is present ? The accompanying table shows the differential 
points for diagnosis. It is seen that the age, occurrence of previous 
attacks, the character of the general symptoms, the existence of pre- 
vious laryngeal disease, the association of faucial disease, the presence 
or absence of membrane, and the results of laryngoscopic examination 
must be considered before making a positive diagnosis. 



Simple Acute Laryngitis. — " Catarrh of 

Larynx." 

Gradual onset of laryngitis, with dyspnoea 

very slight or absent. 
All ages. 

Fever of varying degree. 
Dry irritating cough. 
May be hoarseness. 
Pharynx reddened. 
Gradual increase and decline. 

Larynx red and slightly swollen, as seen 
by laryngoscope. 

Acute Laryngitis with Spasm. — Spasmodic 
Croup. 

May be slight hoarseness or cough, or 
none. Suddenly, in night, child wakes 
with intense dyspnoea and crowing in- 
spiration. 

Children. 

Temporary high fever. 

Slight brassy cough during day. 

May be slight hoarseness in day. Very 
hoarse in attack. 



Lasts a few minutes to one hour. May 
recur, or no attack until next night. 

Slight redness, or nothing seen by laryngo- 
scope. 

(Edema of Larynx. 
Some inflammatory disease of larynx exists. 
Rapid development of dyspnoea, increasing 
to great severity. 



All ages. 

Depends on cause. 
No cough. 
No hoarseness. 



Increases steadily to climax, then death, 
or decline of dyspnoea. 

Epiglottis and aryteno- epiglottic folds 
swollen, pale, and waxy. 



Acute Laryngitis with Stenosis. 

Gradual onset of laryngitis, but dyspnoea 

develops to great severity. 
Children. 

Fever of varying degree. 
Dry cough, often paroxysmal. 
Hoarseness. 
Pharynx reddened. 
Gradual increase, and either death of 

patient or decline of dyspnoea. 
Same, but swelling much greater. 



Laryngismus Stridulus. — u 'Child-crowing. ," 

No laryngitis. Sudden attacks of dyspnoea 
with crowing inspiration, either day or 
night. Very severe. May be general 
convulsions. 

Children or hysterical adults. 

No fever. 

No cough. 

No hoarseness. 

Occurs often in rhachitic and hysterical 

cases. 
Ends suddenly, in at most two minutes, 

and occurs often. 
Nothing seen in larynx. 

Membranous Laryngitis. — Croup ; 
Diphtheria. 

Epidemic. 

Gradually developing hoarseness and 
croupy cough, with low fever and lassi- 
tude, then development of dyspnoea, 
gradually and without intermission, as 
a rule. 

Children 

Low fever and depression. 

Croupy cough, later suppressed. 

Very hoarse. 

Fauces red and often with membrane ; 
albuminuria ; paralysis. 

Increases steadily, broken by intense par- 
oxysms. Either death or gradual im- 
provement. 

Red, swollen, with membrane. 



THE NOSE AND LARYNX. 445 

Foreign Bodies. Pertussis. — Whooping-cough. 

During eating or while holding object in Epidemic, 
mouth sudden dyspnoea, varying in in- 
tensity according to object. 



All ages. 

No fever. 

Irritative, expulsive cough. 

May be hoarseness or not. 



Cough persists till removal of body, or 
occasionally the larynx becomes accus- 
tomed to its presence, and cough ceases. 

See the foreign body. 



Bronchitis, with cough developing in from 
one to three weeks. Then dyspnoea 
caused by severe paroxysm of coughing 
— absent between them. 

Children. 

Only the fever due to bronchitis 

Intense paroxysm of coughing. 

No hoarseness. 

Hemorrhages in various places from strain 
or emphysema. 

May be death from exhaustion, or gradual 
improvement. 

Nothing seen, unless slight laryngitis. 



Acute Submucous Laryngitis. The inflammation extends to the 
submucous cellular tissue. It arises in the course of acute laryngitis, 
and is the form seen in traumatism, or from burns and scalds. The 
symptoms are those of intense laryngitis, with stridor. They increase 
in severity until stenosis arises. If the under surface of the cords is 
affected, death will occur from asphyxia. Sometimes the inflamma- 
tion is circumscribed and is followed by development of an abscess. 

The chronic form of submucous inflammation of the larynx is usually 
seen in drunkards, and is recognized usually by the laryngoscopic 
examination. The symptoms are those of slight stenosis. 

Paralyses of the Laryngeal Muscles. 

They are divided for convenience into groups. The symptom is 
dysphonia, which, with laryngoscopic appearances, leads to the recog- 
nition of the paralysis. 

1. Paralysis of the Tensors of the Cord. The crico-thyroid 
muscle is paralyzed ; the superior laryngeal nerve which supplies the 
muscle is concerned. The voice is deep and rough, and incapable of 
producing high tones. Usually, the whole nerve is involved, and the 
result is anaesthesia of the larynx and paralysis of the epiglottis. 

Laryngeal Examination. The epiglottis is fixed, and falls back 
against the tongue. The glottis opening is a wavy line. 

Causal disease. The condition described occurs almost exclusively 
after diphtheria. 

2. Paralysis of the Closers of the Glottis, or Adductors of the 
Cords. The muscles involved are the crico-arytenoideus lateralis, 
arytenoideus transversus, and the thyro-arytenoideus internus and 
externus. The nerve is the recurrent laryngeal. 

The symptoms are complete aphonia, coming on suddenly, and often 
disappearing as suddenly. 

Laryngeal Examination. During phonation the cords remain in the 
inspiratory position. The paralysis may affect one or both sides. 

Sometimes the arytenoideus transversus alone may be affected. Then 
there is hoarseness or aphonia. The anterior portions of the cords 
come together in phonation, but the posterior portions do not, leaving 
a triangular opening posteriorly. (See Fig. 118.) 



446 SPECIAL DIAGNOSIS. 

Or, the thyro-arytenoideus interims alone may be affected. There 
is then dysphonia or aphonia, as before, bnt the cords come together 
at both extremities and remain apart in the middle, forming an oval 
opening. (See Fig. 119.) 

Fig. 118. Fig. 119. 





Paralysis of the arytenoideus transversus in Paralysis of the thyro-arytenoideus interims 

phonation. (Gottstein.) , in phonation. (Gottstein.) 

Causal Disease. These paralyses occur in hysteria, catarrh, or severe 
overstrain of the voice. 

3. Paralysis of the Openers of the Glottis, or Abductors of the 
Cords. The muscle affected is the crico-arytenoideus posticus, and 
the nerve is the recurrent laryngeal. 

Symptoms. When one side is affected the respiration is free, but there 
is stridor or forced inspiration. The voice is harsh. 

Laryngeal Examination. One cord remains in the middle line. (See 
Fig. 120.) 

When both sides are affected there is gradually developing inspira- 
tory dyspnoea with stridor. The voice is nearly normal. 

Fig. 120. 




Paralysis of the left recurrent nerve ; inspiration. (Gottstein.) 

Laryngeal Examination. The glottis is a narrow cleft which be- 
comes still narrower on inspection. 

Complete Paralysis of the Recurrent Laryngeal Nerve. Symp- 
toms. Unilateral Paralysis. A weak, toneless voice which breaks 
into a falsetto when the patient endeavors to speak loud. 

Laryngeal Examination. The cord and arytenoid body are in the 
cadaveric position — viz., half-way between the phonating and the inspi- 
ratory positions. In phonation the other cord passes beyond the middle 
line, and the glottis is slanting. The edge of the paralyzed cord is 
excavated. 

Bilateral Paralysis. Aphonia and inability to cough and ex- 
pectorate. 



THE NOSE AND LARYNX. 447 

Laryngeal Examination. Both cords are in the cadaveric position 
and their edges excavated. 

The adductors are usually paralyzed before the abductors, and one 
can see all the intermediate stages by close watching. 

Causal Disease. The conditions which give rise to the paralysis 
are numerous. It may arise from simple catarrh or from hysteria. 
More often it is due to pressure on the vagus or recurrent laryngeal, or 
some disease affecting these nerves or their roots. 

The causes of pressure are : Aneurism of the subclavian or aorta, 
mediastinal tumor, tubercular bronchial glands, the apex of a tuber- 
cular lung, cancer of the oesophagus, goitre, or carcinoma of the pleura. 

The diseases are : Diphtheria, tumor, softening or hemorrhage into 
the brain, bulbar paralysis, neuritis, typhus, cholera, variola, articular 
rheumatism, toxaemia (?), sclerosis of the cord, progressive muscular 
atrophy, and paralytic dementia. 

Tumors of the Larynx. 

Both benign and malignant growths are seen. At first dysphonia 
or aphonia takes place. The impairment of voice may continue for a 
long period of time before dyspnaia arises. This develops very gradu- 
ally, and in some few cases is attended by an irritative cough. The 
general symptoms are not marked in benign cases. In the malignant 
forms they are pronounced, but characterized by the development of 
cachexia later than in carcinoma elsewhere. 

The diagnosis of malignant disease of the larynx is based upon the 
association of symptoms of laryngeal disease with pain, and with the 
characteristic appearances found on inspection, on its occurring after 
the middle period of life, and lasting from six to nine months only, 
with the development of cachexia and emaciation without fever. En- 
largement of the cervical glands points to cancer. Simple and syph- 
ilitic perichondritis must be excluded. 

Tuberculosis of the Larynx. 

The existence of primary laryngeal tuberculosis is doubtful. It 
cannot be proved clinically, and the majority of cases, at least, are 
secondary to tuberculosis of the lungs. The manifestations of tuber- 
culosis of the larynx may be either a simple persistent catarrh, an in- 
filtration, or an ulceration. (See pages 439 and 440.) The symptoms 
vary according to the lesion. 

a. Catarrh. There is a slight hoarseness and the voice tires easily. 
Often paresthesia or peculiar sensations in the larynx are present. 
Cough, when due to this alone and not to the process in the lungs, is 
short and dry. 

b. Infiltration. At first the symptoms are those of simple 
catarrh, then the alteration of the voice increases even to aphonia ; 
there is a feeling of dryness or soreness in the larynx, and dysphagia. 
The cough is very slight and is usually wholly disguised by the cough 
due to the disease in the lungs. There is some difficulty in expecto- 
ration. 



448 SPECIAL DIAGNOSIS. 

c. Ulceration. The symptoms are the same as those of infiltra- 
tion, but the dysphagia and pain are greater. 

Diagnosis. Tuberculous ulcer occurs most frequently in the male 
sex, and during the period ranging from eighteen to thirty years of 
age. If the symptoms develop in the course of phthisis, or in case 
that affection cannot be recognized, if there is a history of infection, or 
exposure, and if bacilli are found in the sputum, the diagnosis is not 
difficult. A portion of the diseased mass may be removed for micro- 
scopic examination or inoculation. In examining the secretion for 
tubercle bacilli, it is to be remembered that the exudation may have 
been brought up from the lungs. The examination in cases of phthisis 
is of little practical value, except to determine whether the ulceration 
present may be syphilitic and grafted upon a tuberculous disease of the 
lungs. Enlargement of the glands of the neck is often present, but is 
not diagnostic. 

Fever is present, and, indeed, may be an important diagnostic 
feature in doubtful cases. The temperature should be taken every two 
hours, for the morning or evening exacerbations may not be present. 
Emaciation ensues, and sooner or later the hectic phenomena and signs 
of tuberculosis in other structures arise. When tuberculous ulceration 
of the larynx occurs in the course of local pulmonary tuberculosis the 
disease runs a much more rapid course. 

The laryngeal symptoms are not diagnostic. Pain may be the most 
distinct. The appearances observed by the laryngoscope are more 
characteristic. Local anaemia with paresthesia, paresis of the cords, 
and short cough, or an obstinate diffuse catarrh, are suspicious symp- 
toms. The peculiar ridged infiltration between the arytenoids is 
almost invariably tubercular. 

Isolated thickenings anywhere in the larynx that taper off gradu- 
ally into the normal tissue can only be tuberculous or syphilitic. The 
regularity and number, Avith anaemia and lack of inflammatory signs, 
will usually distinguish the tuberculous from the syphilitic. The 
ulcers are non-erosive. Syphilitic ulcers do not often occur, except on 
the edge and lingual side of the epiglottis and on the cords. They 
extend more rapidly than the tuberculous, and may be continuous with 
ulceration in the pharynx. The area of ulceration may extend to the 
base of the tongue, which is very infrequent in tuberculous disease. 
In syphilitic ulceration scars or cicatrices are seen, but they are absent 
in the tuberculous form. Laryngoscopic examination in tuberculous 
ulceration is difficult, as it causes great pain ; in syphilis comparatively 
little pain attends examination. (See the Infections.) ■ 

Syphilitic Affections of the Larynx. 

Mucous patches, papules, infiltrations, or gummata may be present 
in the larynx for some time without exhibiting any symptoms. Usu- 
ally a change in the voice is the first symptom noticed, due either to 
the catarrh or to ulcers, scars, infiltrations, or gummata affecting the 
cords. There is often a feeling of pressure or a tickling sensation. 
Pain is not usual, and, when present, is very slight. Dysphagia 



THE NOSE AND LARYNX. 449 

occurs only when the epiglottis is extensively ulcerated. There is 
little or no cough. 

The diagnosis rests upon the history of infection, the objective signs 
of syphilis indicated by pigmentation or recent eruption, scars, perios- 
titis or nodes on the bone, and enlarged glands. The laryngeal symp- 
toms are not diagnostic, save that pain is absent in spite of extensive 
ulceration, while difficulty of deglutition, on account of food entering 
the larynx, is of frequent occurrence. The laryngoscopic appearances, 
as indicated above, are characteristic of this affection. In obscure 
cases the distinctions spoken of in tuberculosis are of diagnostic value. 

Although the patient may be broken down and cachectic the febrile 
range is not high, unless perichondritis occurs, or pneumonia sets in, 
on account of food in the air-passages. 

The Larynx in Other Diseases. 

Laryngeal symptoms due to lesions of the nervous system are found 
under the following circumstances. (See Cerebral Localization.) 

Cerebral Hemorrhage. 1. Aphasia. The movement of the 
muscles is normal, but they cannot be controlled by the will. Caused 
by hemorrhage in the cortex or along the course of connective fibres. 

2. Recurrent paralysis. Due to hemorrhage in the medulla. 

3. Symptoms of bulbar paralysis. Same cause. 
Encephalomalacia. (Softening.) When in the brain, aphasias 

result ; Avhen in the medulla, bulbar symptoms. 

Tumors of Cerebrum. The symptoms are, according to location, 
aphonia, aphasia, or paralysis of the cords. 

Bulbar Paralysis. We have, of course, the other symptoms of 
the disease. The voice becomes weak and monotonous without modu- 
lation. High tones are impossible. It progresses to hoarseness and 
finally aphonia. Particles of food and drink enter the larynx. Paresis 
or paralysis of the cords. 

Multiple Sclerosis. The speech is low, uncertain, and scanning, 
later hoarse. Laughing and crying are accompanied by peculiar yawn- 
ing inspirations. Laryngoscopical examination : Slight paresis of the 
cords is seen. 

Posterior Sclerosis (Tabes). The muscles act very slowly. 
Sometimes symptoms of irritation, as tickling or burning in the larynx, 
with a dry cough, occasionally severe paroxysms of coughing, even to 
spasm of the larynx, occur. " Laryngeal crises." In rare cases a 
phonetic spasm has been observed. Less often paresis or paralyses of 
the various muscles occur, most frequently the posticus, next the 
recurrent. Sensibility may or may not be disturbed. 

Amyotrophic Lateral Sclerosis. There is a mixture of bulbar 
with spinal symptoms. (See Sclerosis.) 

Progressive Muscular Atrophy. The same mixture of symp- 
toms occurs very late. 

Paralytic Dementia. There may be disturbances in articula- 
tion, with paresis and paralysis of the cords. 

Chorea. There may be a tremor of the cords from under-tension, 
but probably no true choreic movements. 

29 



CHAPTER II. 

DISEASES OF THE LUNGS AND PLEUE^E. 

The lungs are composed of a relatively small amount of tissue. 
They are made up of tubes and canals. The tissue which composes 
the structure of the lungs independently of the canals, the connective 
tissue, is liable to the same morbid processes that affect it in other situ- 
ations. But, curiously, it is not often subjected to irritants which cause 
acute inflammation, while chronic inflammations occur secondarily, in 
the large majority of cases, to processes in the channels. Diseases of 
the lungs are really the disease of its channels, and the symptoms that 
arise are due to morbid alterations of them (1) by processes common 
to the structure of such channels and (2) by obstruction of them. 
There are three sets of channels : First, for the passage of air ; second, 
for the flow of blood ; and, third, for the flow of lymph. The symp- 
toms, therefore, are due to the morbid process or to obstruction of the 
channels just mentioned. 

Physical Classification. The various affections of the lungs occur 
without any change in the volume of air in the lungs, or are attended 
by an increase or diminution in the amount of air. 

I. Diseases with Normal Amount of Air. 

Affections of the Bronchial Tubes, except Asthma. 

II. Diseases with Increased Amount of Air. 

Enlargement of the Chest. The enlargement with in- 
creased amount of air may be unilateral or bilateral. It 
seems paradoxical that the more air there is in the thorax, 
the greater is the need for air, and hence the occurrence of 
dyspnoea. 

1. Asthma. 

2. Emphysema. 

III. Diseases with Diminished Amount of Air. 

A. The Consolidations. The consolidations may be local, 
unilateral, or bilateral. 

1. The congestions. 

2. Pulmonary embolism and thrombosis. 

3. Pneumonia. 

4. Bronchopneumonia. 

5. Chronic interstitial pneumonia. 

6. Pulmonary tuberculosis. 

7. Abscess of the lung. 



DISEASES OF THE LUNGS AND PLEURJE. 451 

8. Gangrene of the king. 

9. Collapse of the lnng. 

10. Cancer and other new growths of the lnng. 

11. Hydatid disease of the lnng. 

B. Diseases of the Pleura. 

1 . Diminished amount of air from inhibition of movement, 

on account of pain. 

2. Diminished amount of air from the physical condition 

within the thorax. 

The Morbid Processes. 

Affections of the lungs may be divided into the neuroses, the con- 
gestions, the inflammations, the degenerations, the morbid growths and 
gross parasites. Influences operating through the pneumogastric and 
phrenic nerve may be responsible for respiratory neuroses. The con- 
gestions are so intimately associated with vascular phenomena that the 
latter may be included in the process. The inflammations are limited 
to the bronchi, to the alveoli, and to the connective tissues surround- 
ing both. The intimate relation of the small bronchi, the alveoli, and 
their surrounding connective tissues implies their conjoint involvement 
in many processes. 

A. The Neuroses. 

B. The Congestions. 

1. Active, including hemorrhagic infarct. 

2. Passive. 

Subsidiary : hemorrhage. 

C. The inflammations, chiefly infectious. 

1. The Bronchi. 

Acute. 
Chronic. 

2. Bronchi and alveoli. 

Bronchopneumonia (an infection). 

3. Bronchi, alveoli, and connective tissue. 

Pneumonia. 

Tuberculosis. 

Abscess of the lung. 

Gangrene. 

Chronic interstitial pneumonia — pneumonokoniosis. 

Syphilis of the lung. 

D. The Degenerations. 

Emphysema. 
Bronchial dilatation. 

E. Morbid growths. 

F. Gross Parasites. 

Hydatid disease. 
Symptoms Due to the Morbid Process. The air-tubes are lined 
with mucous membrane, which is subject to morbid processes that 
attend any such lining — congestion, or acute and chronic inflammation 



452 SPECIAL DIAGNOSIS. 

— with a flux as the characteristic symptom. The muscle and elastic 
tissue of the canal become involved in the process. The former un- 
dergoes spasm, with or without mucous membrane inflammation 
(asthma). Grave consequences do not arise until degeneration takes 
place, then the power of confining the air or driving it out is lost, 
and emphysema results. 

In the blood-canals, hyperemia (congestion), embolism and throm- 
bosis, and secondary oedema take place ; in the lymph-canals, inflam- 
mation (acute and chronic pleurisy), and transudation (hydrothorax or 
hemothorax). Now, the symptoms that arise in each or all of the above 
processes — pain, local discomfort, mucous or purulent discharge, serous 
or purulent exudation, and fever — are not different from those which 
are found in diseases of similar tissues in other localities. (Compare with 
affections of mucous membranes in other organs or of serous membranes). 

Symptoms Due to Obstruction of Channels. In addition to these, 
however, there is a group of symptoms due to obstruction of the various 
channels, and hence, interference with the function of the lungs. The 
symptoms are purely mechanical. 

1. Dyspnoea occurs from obstruction of either the bronchial tubes 
or bloodvessels in addition to causes mentioned below. It is as pro- 
nounced in asthma or capillary bronchitis as in embolic obstruction 
(fat-embolism) or congestion and stasis in the bloodvessels. It occurs 
when the canals are occluded by extrinsic causes — foreign bodies in 
the bronchi or pleural effusions. 

2. Cyanosis. As a sequence of the above symptoms we have 
another vivid picture — the development of cyanosis from interference 
with aeration. 

Symptoms Due to Altered Muscle or Nerve Mechanism. 
Other structures (the bony thorax and its muscles) are required for 
the performance of the function of the lung, the aeration of blood. 
Of these we have more particularly : first, muscles, to hasten the 
movement of the air ; and, second, a nervous mechanism to control 
the movement of the muscles. 1. Inactivity of the former, from pain, 
from debility, or from paralysis through disease of the nerves, practi- 
cally occludes the canals, for the normal contents slacken or cease 
their movement, and therefore the amount of air is lessened — hence 
dyspnoea. 2. The nervous mechanism not only controls the large 
muscles of the exterior, through a centre stimulated or depressed 
by various influences, chiefly the blood, but also receives and sends 
impressions to the muscles of the tubes, giving rise to (a) cough 
or (b) bronchial spasm with dyspnoea. This nervous mechanism by its 
centre of control is in relationship with higher and lower centres, and 
the nerve that connects it with the bronchial tubes supplies other organs 
or anastomoses with other nerves. Hence, we may have : A. A central 
affection, causing pulmonic symptoms from the following causes : 1. 
Because higher centres influence the lower pulmonary centre, as we see 
in hysterical cough, or emotional cough, and in asthma — respiratory 
neuroses. 2. Disease affecting the region of the centre, as in tumor or 
in bulbar or glosso-labio-laryngeal paralysis. 3. Irritants acting upon 
the centre, as urea, exciting ursemic asthma. B. An affection of the 



DISEASES OF THE LUNGS AND PLEUEJE. 453 

nerve-trunk, as from the pressure of an aneurism or morbid growth. 
C. Reflex influences through the pneumogastric and correlated nerves. 
The asthma of nasal disease, or of peripheral irritation, and reflex 
cough (neuroses) are of this nature. Corollary ; Lung symptoms, chiefly 
dyspnoea and cough, may be due to local causes (affections of the mus- 
cles), or to causes at a distance, operating directly through the pneu- 
mogastric centre, or the nerve-trunk, or by anastomoses in a reflex 
manner. The practical deduction is to look further than the lungs in 
the investigation of pulmonic symptoms. Lung symptoms are not 
often expressive of disease in other parts, nor are diseases of the lungs 
symptomatic of disease in other organs. 

Affections of the Pleura. In diseases of the pleura, one side is 
usually affected. Simple inflammation and inflammation with exuda- 
tion into the pleural cavity occur. In both forms there is diminution 
of movement, and hence less air entering the affected lung, although 
the cause is different in each case. In acute inflammation, the dimin- 
ished amount of air is for physiological reasons : the movement of the 
affected side is inhibited by pain — hence diminution of expansion and 
lessened ingress and egress of air. Enfeeblement of breath-sounds and 
fremitus, with diminished expansion, alone indicate the diminution. 
On the other hand, in acute inflammation with exudation, the amount 
of air is diminished for physical reasons. The effusion encroaches 
upon and causes diminution of the air-space, and hence lessens the 
amount of air. It Avill be remembered that the physical signs of dimi- 
nution in the amount of air from effusion are quite distinct from the 
physical signs due to consolidation. 

The Lungs and Heaet. The relationship of the pulmonary vas- 
cular channels to the remainder of the circulation is very close. Over- 
filling of the pulmonic bloodvessels, and hence dyspnoea, may be due 
to alterations or changes in the central pump, the heart ; or in the 
vessels between— as from the pressure of an aneurism. The nature 
and importance of lung symptoms cannot be appreciated without an 
investigation of the heart and the blood-ways. Many pulmonic con- 
gestions are due to dilatation of the heart, and are relieved by digitalis. 
At the other end of the beam, it may be noted that lung diseases cause 
heart disease ; from backward pressure of blood-columns in over- 
distended vessels, a dilated right heart follows. 

Space forbids tracing out the effects of the blocking of channels, but 
it is suggestive that all the aeration of the body takes place through 
the first set of tubes, that all the blood of the body passes through the 
second, and that the third is an enormous drainage-area of lymph. 
The student can readily appreciate how profoundly diseases of the 
lungs must affect the general system. Apart from the nerves, the tie 
that binds the other organs to them is the blood. In proportion as the 
lungs enrich them with oxygen, the other organs act with vigor. Im- 
perfect oxygenation soon causes diminution of all function, with the 
secondary effect on the blood of the production of ancemia, which, with 
its long train of symptoms, is seen in all chronic lung affections. 

Relative Value of Subjective and Objective Symptoms. The 
subjective symptoms are few, and, as will be seen later, are common 



454 SPECIAL DIAGNOSIS. 

to so many pulmonary diseases that they are of little diagnostic value. 
The objective symptoms are more decisive, and the laws of physics as 
applied to the lungs aid in the distinction. The effect of the occlusion 
of channels is mechanical or physical, and hence a physical change in 
the lung follows. The objective symptoms occur (1) because of the 
physiological movement of air. Sound attends the movement of air 
in health ; if the air-movement is checked, no sounds occur, or abnor- 
mal breath-sounds and new sounds (rales) are created. They also 
occur (2) because of physical changes in the structure. Air is replaced 
by solid structure ; the physical condition of the lung changes. The 
objective signs of these conditions are determined by inspection, palpa- 
tion, percussion, and auscultation. 

Diagnosis. The diagnosis of disease of the lungs is attained by the 
collection and consideration of data obtained both by inquiry and by 
observation. By observation the objective phenomena are secured, 
first, by physical examination ; second, by an examination of the 
sputum ; and, third, by an examination of the fluids secured by punc- 
ture. 

It is not usually difficult to distinguish diseases of the lungs from 
affections of other structures. It is true, pleurisy and pleurodynia are 
often distinguished with difficulty. We are called upon, also, to decide 
between pleurisy and subdiaphragmatic inflammation, a pleural and 
hepatic inflammation, a pleuritis and pericardial inflammation, and 
between cardiac and pulmonary disease, especially when both are pres- 
ent and it is desirable to determine which is the primary affection. 
The contiguous relations of the organs make this necessary, and with 
care in ascertaining the history and the subjective and objective symp- 
toms the distinction may not be difficult. 

In chronic disease, affections of the lungs, of the mediastinum, and 
of the great vessels must be distinguished from one another. An 
aneurism or mediastinal disease may simulate chronic phthisis. 

Infections. It often happens in a pulmonary disease that some of its 
pronounced symptoms may strongly point to an infection other than 
that of the lungs ; thus the cerebral symptoms of pneumonia may be 
held to be due to meningitis, or the fever thought to be due to typhoid 
fever. On the other hand, the presence of a pulmonary affection, as 
tuberculosis, may explain the nature of the morbid process in other 
organs or structures. Hence, in all cases in which there is a possibility 
of secondary tuberculosis the lungs should be examined to determine if 
they are the seat of the primary disease. In this way the true nature 
of a meningitis, a peritonitis, or other tubercular affection may be recog- 
nized. So, too, in secondary anaemia and in protracted debility of un- 
known source the lungs should be examined. It must be borne in 
mind also that in chronic diseases, as chronic renal disease, chronic 
arthritis, diabetes, etc., pulmonary tuberculosis may set in most insidi- 
ously. In the same class of diseases pneumonia is frequently a ter- 
minal infection, and likewise runs an insidious course. Finally, in 
the extremes of life pulmonary infections, as pneumonia, present symp- 
tom- out of the usual run. In infancy and childhood the cerebral 
symptoms may mask the pulmonary symptoms ; in senility the ab- 



DISEASES OF THE LUNGS AND PLEURJE. 455 

sence of cough or expectoration may lead to the dismissal of all thought 
of pulmonary disease. In short, the lungs should be examined in all 
affections. 

This injunction is particularly to be observed, as lung diseases are 
often secondary to other diseases ; phthisis, to tuberculosis elsewhere, 
pneumonia or pleurisy to all infectious disorders, to Bright' s disease, 
cancer, and diabetes. Above all, the possibility of a hydro thorax, 
secondary to causes of transudations, must be borne in mind. 

The Data Obtained by Inquiry. 

The Social Histoey. A glance at the various processes which 
take place in the lungs readily lead one to infer the social history. 

Age. In the earlier and later periods of life bacterial invasion is 
more likely to take place ; hence, at these extremes streptococcus and 
pneumococcus infections are common ; tuberculosis, on the other hand, 
is more common in early adult life, although it does not respect age. 
The degenerations are more common later in life, as we may say of the 
morbid growths, both obeying the usual rules concerning the course of 
these processes. The sex. As the infections predominate and as one 
at least is more liable to develop in those whose resistance is lessened, 
it follows that tuberculosis is more frequently seen in the female sex. 
That sex which follows occupations compelling the inhalation of irri- 
tating particles — the male — is more liable to have fibroid and other 
inflammations of the lungs. 

The Occupation. From this we gather little of diagnostic value, 
save that the chronic inflammations are more prone to occur in those 
who inhale solid particles, as miners, stone-cutters, etc., while tubercu- 
losis attends those whose occupations are debilitating and require in-door 
duties. Nor does a knowledge of the habits lend much aid save as 
they depress the system and render it more vulnerable to bacterial 
action. It is needless to say clothing, exposure, residence, and the 
diet may be hygienic factors in the life of the patient. The amount 
of exercise, etc., must be inquired into in each case. 

Infections. It is readily seen, however, that the facts in the social 
history of diagnostic importance are just those facts which are predis- 
posing factors in many infectious disorders. Most lung diseases are, 
therefore, correlated in their antecedents with the infections. It must 
be borne in mind it is always well to trace the source of the infection if 
possible. 

The Family Histoey. Heredity plays a serious part, and hence 
the family history should be sought for, particularly in the study of 
those affections which are of tuberculous origin. The tendency of this 
infection to follow in successive strains is well known. In like man- 
ner we inquire in cases of asthma and other neuroses for evidence of 
their occurrence in previous generations — a well-known clinical fact. 
Then emphysematous changes seem to be a peculiarity of certain fam- 
ilies. 

The Occueeence of Peevious Diseases is to be inquired for. 
Pneumonia is likely to be followed by other attacks. Pleurisy is 



456 SPECIAL DIAGNOSIS. 

related to, and may be an expression of rheumatism ; it may be pre- 
ceded by other rheumatic phenomena ; it may be the earliest expres- 
sion of tuberculosis, and may precede the latter by two or more years, 
an interval of health separating the two. Then it must be borne in 
mind pulmonary tuberculosis may succeed a long antecedent joint or 
glandular tuberculosis — a history of which should be inquired for. 
The state of the circulation should be studied, and the occurrence of 
previous heart disease sought for. In affections of the pleura we must 
inquire for previous infections and note the presence or absence of 
disease of contiguous structures, as the ribs and muscles of the chest 
and the viscera below the diaphragm. 

The Subjective Symptoms. Dyspnoea. Dyspnoea, in its true 
sense, means difficult breathing. The respirations are deeper than 
natural, but of normal frequency, or they may only be more frequent 
than they should be, or they may be both deeper and more frequent. 
The patient is usually conscious of suffering or of some distress in 
breathing. Lung disease without dyspnoea : While a common, indeed 
almost constant symptom of lung disease, it does not follow that be- 
cause a patient has extensive disease of the lung he need suffer from 
difficult or hurried breathing. This is because the system requires no 
more air than the capacity of the lung is able to supply. The change 
takes place very gradually, but many persons with chronic fibroid 
phthisis, or with emphysema, in both of which the disease may be 
extensive, may not have dyspnoea, unless an unusual demand is made 
upon the system. The subjects are under-weight, move slowly, and 
otherwise show that they are deprived of an essential to active being. 

Varieties of Dyspncea Depending upon Cause. 

I. Anything which cuts off or lessens the normal amount of air re- 
quired for oxygenation of the blood. A. Obstruction of the air-pas- 
sages. B. Diminution of air-space from causes within and outside of 
the thorax. C. Interference with the action of the muscles concerned 
in breathing. 

II. Affections which lessen the amount of blood, as obstructive 
heart disease. Rarely, tumors pressing upon the bloodvessels. 

III. Affections in which the red blood-corpuscles are diminished — 
anaemia. 

IV. Pulmonary embolism and thrombosis. In cases of weak heart 
the vessels become occluded. After labor a clot of blood may escape 
from a uterine sinus, be carried to the right heart, and thence to the 
pulmonic veins. The clot may arise from inflammation of the veins 
in any situation. 

V. Fat-embolism. Foreign substances in the blood, as fat, occur- 
ring in parturient women three or four days after labor, after frac- 
tures, and in diabetes. 

VI. Dyspnoea due to interference with the nervous mechanism of 
respiration, a. Tumor, hemorrhage, or degeneration about the respi- 
ratory centre in the medulla. 6. Irritation of the centre by toxic 
agents, as in uraemia, diabetes, auto-intoxication from gastro-intestinal 
disorder. To this class belongs u heat dyspnoea/' which occurs in all 
f eb rile conditions. The warm blood acts as a direct irritant to the 



DISEASES OF THE LUNGS AND PLEURAE. 457 

respiratory centre in the medulla oblongata (Landois). This explains 
the dyspnoea of fever and the curious fact pointed out by Cohnheim, 
that the respirations in pneumonia lessen as soon as the fever disap- 
pears, notwithstanding the persistence of the physical condition, which 
may have accounted for the dyspnoea. Reflex dyspnoea (asthma, q. v.) 
belongs to this variety. The dyspnoea of hysteria is of the same class. 

Anything which cuts off or lessens the normal amount of air required 
for oxygenation of the blood causes more or less dyspnoea. 

A. Obstruction of the Air-passages. 

1. Occlusion of the nares, unless compensated by mouth-breathing. 

2. Enlargement of the tonsils, retropharyngeal abscess, or any ob- 
struction in the throat, from diphtheritic or (Edematous swelling. 

3. Disease of the larynx, causing stenosis, also causes a characteristic 
form of dyspnoea known as inspiratory dyspnoea. (See Disease of the 
Larynx.) 

4. Obstruction of (a) the trachea or (6) the bronchus from external 
pressure or from a foreign body. It must be distinguished from 
dyspnoea, the origin of which is higher up in the air-passages, by 
careful inspection. 

a. Tracheal Obstruction. In this form of dyspnoea there is no 
increased movement of the larynx. There is no change in the voice, 
except that it may be weakened, and the sonorous quality diminished. 
The voice will be modified, however, if there is at the same time 
disease of the larynx from syphilis, or paralysis of the muscles 
from pressure on the recurrent laryngeal nerves by the same cause as 
the tracheal stenosis. If so, on laryngoscopic examination the tumor 
pressing upon the larynx can be seen at times, especially if the larynx 
is healthy. 

Expert operators can secure quite an extensive view of the wind- 
pipe, particularly if the head is bent slightly forward and the patient 
is seated in the upright posture. A mirror must then be placed 
against the soft palate, with the surface more horizontal than usual. 
By this means an aneurism may be seen bulging into the trachea. It 
must not be mistaken for pulsation of the lower end of the trachea, 
due to transmission of the impulse of the aorta to the trachea, which 
has been shown to occur in healthy persons. 

The dyspnoea is expiratory, and is never so extreme as in laryngeal 
stenosis. The lower ribs are therefore not sucked in during inspira- 
tion until late in the disease. A stridor attends the dyspnoea, which is 
heard with the stethoscope over the trachea, as well as over every part 
of the chest. Sometimes a point over the trachea can be determined 
at which the sound is heard loudest. The point may indicate the seat 
of a stenosis. Sometimes the sound is more marked over the larynx 
than over the sternum, when the lower part of the trachea is obstructed. 
Demme has pointed out that in cases of prolonged obstruction in the 
lower air-passages the upper portion of the thorax may diminish in 
size. Not only is the dyspnoea constant, but paroxysms may take 
place in which the distress is very severe. These paroxysms of dysp- 
noea may be due to spasm of the vocal cords ; but it is very likely that 
they are due, as Bristowe has shown, to swelling of the mucous mem- 



458 SPECIAL DIAGNOSIS. 

brane, or to mucus which has accumulated at the point of obstruction 
and cannot be dislodged, or to spasm of the muscular tissue of the 
trachea itself. In addition to the subjective symptom of want of breath 
the patient may complain of pain or oppression behind the sternum, 
or possibly only of a slight soreness. Cough usually attends the dysp- 
noea, with expectoration of mucus. Sometimes the mucus is blood- 
tinged, and even streaks of blood may be expectorated after a consid- 
erable time, in cases of leaking aneurism. 

If the obstruction is due to a foreign body, the dyspnoea is of the 
same type, but occurs suddenly. 

b. Bronchial Obstruction. Laryngeal movement is not in- 
creased and the voice is not changed. If a bronchus is obstructed, 
the lung of the unobstructed bronchus becomes the seat of emphysema. 
When obstruction takes place gradually, compensatory emphysema 
occurs, developing slowly, not rapidly as in the former instance, the 
degree depending upon the amount of obstruction in the opposite 
bronchus. The physical signs over the lung of the obstructed bron- 
chus are pronounced. The vesicular murmur is absent, the fremitus 
is absent, the movement of the affected side is impaired. With these 
changes the percussion-sound is normal at first, although its limits are 
influenced less by forced inspiration and expiration ; later, it progresses 
from impaired resonance and dulness. As the case advances, the affected 
side may fall in and measure less than the opposite side. A snoring or 
whistling sound may be heard over the root of the lung, between the 
scapula and vertebrae, or moist rales may be present. 

The causes of tracheal and bronchial obstruction are : (a) External 
pressure. First, tumor of the thyroid gland ; second, thoracic aneu- 
rism ; third, mediastinal tumor from other causes than aneurism, as 
disease of the glands, cancerous or tubercular, or mediastinal abscess ; 
fifth, cancer of the oesophagus; and, finally, in rare cases, a dilated 
auricle, (b) Diseases of the walls of the trachea. They cause obstruc- 
tion by narrowing the calibre. Syphilis is the most frequent cause of 
such obstruction, (c) Foreign body. The presence of a foreign body 
within the lumen causes obstruction. The foreign body may remain 
free for a time, moving up and down as the patient coughs, and, indeed, 
it may be felt against the side of the trachea when the finger is placed 
outside the neck. Later, the foreign body usually becomes fixed in the 
right bronchus, or one of its main divisions, because the opening of 
the right bronchus is more direct than that of the left. In some in- 
stances the body may be dislodged and fall into the opposite bronchus. 
Rarely it falls first into the left. 

B. Diminution of the Air-space in the Lungs. All forms of 
pulmonary disease attended by consolidation, by compression of the 
lung, or occlusion of the small bronchi, are included under this sub- 
division. The degree of dyspnoea, of course, depends upon the extent 
of the diminution in the air-space. In pleural effusions from any cause 
the air-space is lessened and dyspnoea occurs. In bilateral effusions it 
is more marked than in unilateral. The severity of the dyspnoea de- 
pends somewhat upon the rapidity with which the effusion takes place. 
In cases of sudden effusion of air, as in pneumothorax, the dyspnoea is 



DISEASES OF THE LUNGS AND PLEURJE. 459 

very alarming at first, but, as accommodation takes place, it is grad- 
ually relieved. In rapid effusion of sernm it is also serious. 

The characteristic form of dyspnoea due to lessened air-space is seen 
when obstruction of the air-tubes takes place on account of spasm. 

Asthma. 

Asthma is a chronic disease caused by spasmodic narrowing of the 
bronchial tubes, and characterized by paroxysmal attacks of dyspnoea, 
diminished respiratory movement of the chest, prolonged expiration, 
attended by a wheezing sound and sibilant rales, and ending abruptly 
with the expectoration of tenacious mucus. The attack may be limited 
to a single nighty or may be prolonged for days, with nocturnal exacer- 
bations. 

Premonitory symptoms are said to occur in about one-half the cases. 
These are for the most part nervous, such as headache, neuralgia, irri- 
tability of temper, vertigo, drowsiness. Hyde Salter found that there 
were premonitory symptoms in 111 out of 226 cases collected by him. 
In 63 they were nervous, in 8 there was profuse diuresis, and in 14 
they were connected with the digestive system. 

The attack itself usually begins during sleep, and often at a regular 
time. It may, however, begin during the day, and at a certain hour, 
independently of sleep. The onset is manifested by tightness across 
the chest and more or less difficulty in breathing. This dyspnoea in- 
creases rapidly and often reaches an extreme degree. The face becomes 
pale and anxious, and may be covered with a cold perspiration ; the 
lips are dusky from insufficient oxygenation of the blood. The patient 
feels smothered, and makes frantic efforts to get his breath, rushing to 
an open window, no matter how cold the weather, or, if unable to 
leave the bed, sitting up with the hands pressed upon the bed so as to 
give purchase to the accessory muscles of respiration. Notwithstand- 
ing that great respiratory efforts are made, the chest moves but little, 
because the lungs are already distended to the extent of a full inspira- 
tion. The patient is unable to expel the contained air, owing to the 
spasm of the bronchial tubes. 

The frequency of respiration is diminished, sometimes to one-half 
the normal ; the rhythm is also altered, inspiration being short and 
gasping, and followed without pause by expiration, which is much 
prolonged and accompanied by a wheezing sound audible to bystanders. 

There is an increased amount of air in the thorax, and inability to 
remove it. The chest is enlarged — barrel-shaped — the movement of 
the chest is lessened and strikingly out of proportion to the muscular 
exertions. The diaphragm is lowered. 

The physical signs are hyper-resonance on percussion ; on ausculta- 
tion, faint, short inspiration, prolonged expiration, and sibilant and 
sonorous rales, more marked on expiration. 

The duration of an attack of asthma varies from half an hour to a 
day or two. In patients with chronic bronchitis it may be prolonged 
for a week or two, with remissions during the day. It may subside 
abruptly or by degrees. 



460 SPECIAL DIAGNOSIS. 

Subsidence of an attack is marked by expectoration, the sputa having 
special characteristics. (See under Sputum.) At first it is made up of 
rounded gelatinous masses, which, when unfolded in water, are seen to 
be made up of spirals. Later it becomes mucopurulent. 

Curshmann's spirals and the Charcot-Leyden crystals are. nearly 
always found. The leucocytes are increased, and 25 per cent, of them 
are eosinophiles. 

The causative factors in asthma are various. About twice as many 
males as females are affected, and there is a marked hereditary ten- 
dency in some families. There is probably some special peculiarity in 
asthmatic patients, but just what it is has not been determined. It may 
reside in the lungs, and may be part of a general constitutional irrita- 
bility (Salter). Bronchitis, emphysema, and heart disease act as causes, 
and so do syphilis, malarial poisoning, and chronic Bright' s disease. 

The above description applies to that form of dyspnoea treated of 
in the text-books as spasmodic asthma, a respiratory neurosis which 
for lack of knowledge is classified as a disease. Up to this time the 
dyspnoea is paroxysmal. Sooner or later it becomes constant. When 
the dyspnoea associated with asthma becomes constant other changes 
have taken place in the lungs. First, there is persistent bronchitis ; 
second, the presence of emphysema. Indeed, in many cases it is diffi- 
cult to ascertain the exact sequence of affections. In emphysema of 
the lungs dyspnoea is constant, but, on exposure to cold or on account 
of an attack of indigestion, more severe paroxysms may occur, as well 
as asthmatic attacks, although the patient is not an asthmatic. On the 
other hand, a patient may have had asthma for a number of years, 
during which attacks of dyspnoea occurred only in paroxysms. As 
time passes the paroxysms become more and more frequent, and 
emphysema develops. With the advent of emphysema the dyspnoea 
becomes more constant. 

Asthma, as above described, is a type of dyspnoea of nervous origin. 
It has just been said that it is due to spasm of the bronchial tubes. 
This may occur from a number of causes : (a) It may be of central 
origin, from irritation of the pneumogastric centre ; (b) it is just possi- 
ble that some disturbance of the trunk of the pneumogastric nerve will 
also cause asthmatic dyspnoea ; but what concerns us most is (c) the 
paroxysmal dyspnoea which arises reflexly from irritation of the ter- 
minal endings of the pneumogastric nerve, or of nerves intimately 
associated with the pneumogastric, in the medulla. (1) Disease in the 
upper air-passages, as polyps, or a hypertrophy of the turbinated 
bones, or adenoid growths, are the most frequent source of paroxysmal 
dyspnoea. Not only in permanent disease of this character do we have 
such dyspnoea, but temporary irritants applied to the nares likewise 
produce it. Various odors, the irritation of micro-organisms, or of 
pollen, or emanations from vegetable life, provoke attacks of nasal 
congestion and reflex dyspnoea. The irritation is propagated through 
the ethmoidal and posterior nasal branches of the nerve, the Vidian 
and nasopalatine nerves, to the septum, and the anterior palatine to 
the middle and low turbinates. (2) Irritation in the fauces and larynx is 
not so likely to cause dyspnoea, yet there is no doubt that the presence 



DISEASES OF THE LUNGS AND PLEUB^E. 461 

of a constant irritant in these situations tends to provoke, or keep in a 
state of excitability, the respiratory tract, so that asthma is more likely 
to persist. (3) To this class of cases belongs the irritation of the terminal 
branches of the pneumogastric nerve in the stomach. Peptic asthma, 
or the asthma of indigestion, may owe its origin to these causes. Often 
the irritation is central, due to the irritating influence of an abnormal 
product of indigestion upon the respiratory centres in the medulla. 
(4) For the same reason we have asthma due to other poisonous sub- 
stances circulating in the blood, as the poison of uraemia. The dysp- 
noea due to this condition usually occurs in paroxysms, but may become 
constant. Sometimes it is the first intimation of the presence of renal 
disease. The dyspnoea of diabetic coma may occur from the same 
cause. The nature of both is recognized more particularly by their 
associate symptoms. The condition of the urine, the odor of the 
breath, and the exhalations, the presence of hypertrophy of the heart 
and of an accentuated second sound, point to a ursemic origin. The 
history and symptoms of diabetes, the odor of acetone on the breath, 
the presence of sugar in the urine, the absence of organic pulmonary 
disease, point to diabetes. The dyspnoea of uraemia cannot be distin- 
guished from other forms of dyspnoea, except by the exclusion of 
cardiac and lung disease. It is often difficult to do this, because 
uraemia so frequently develops after the hypertrophied heart has failed, 
so that the physical signs of dilatation may be sufficient to explain the 
dyspnoea. The dyspnoea of diabetic coma, known as " air-hunger," is 
characterized by slow and deep respirations. Cheyne-Stokes respira- 
tion is due to the same cause — namely, irritation in the medulla, as in 
other forms of nervous dyspnoea. It must not be forgotten that the 
dyspnoea of uraemia may present the Cheyne-Stokes phenomenon. 

Diminution of Air-space from Extrapulmonary Causes. 
Anything which crowds upon the thorax, interfering with pulmonary 
expansion, causes dyspnoea. This is notably the case in affections 
below the diaphragm. Hence, in enlargements of the various organs 
of the abdomen, as the liver, spleen, kidneys, pancreas (cystic disease), 
and uterus, dyspnoea always occurs. In accumulations of gas (flatu- 
lency), or of fluid (ascites), the diaphragm is pressed upward and 
encroaches on the thoracic capacity. In abdominal tumor, as of the 
ovary, the omentum, and of the organs above mentioned, dyspnoea is 
a distressing feature. 

0. Interference with the Action of the Muscles. Practically 
any derangement of the action of the respiratory muscles diminishes 
the air-space, as expansion of the lungs is interfered with. Neverthe- 
less, the cause of the dyspnoea is extrapulmonary. It is due to weak- 
ness or paralysis of the muscles concerned in breathing, or to inhibi- 
tion of their action on account of pain, or to interference with their 
action on account of obesity, myxoedema, or oedema, or on account of 
actual disease, as in trichinosis or myositis. 

1. Phrenic dyspnoea is a peculiar form due to paresis of the phrenie 
nerve and consequently to interference with the action of the diaphragm. 
It may not be observed as long as the patient is at rest. Upon slight 
exertion the effort distresses him and causes an increase in frequency 



462 SPECIAL DIAGNOSIS. 

of the respirations. After a few steps a sense of suffocation ensues, 
or upon ascending an elevation the patient must stop frequently to 
take breath. 

Other physiological processes are affected in phrenic dyspnoea. In 
the act of sighing the patient feels as though the abdominal organs 
were drawn up into the chest. Any straining effort, as defecation, is 
rendered difficult. The voice is weak, and there is difficulty in cough- 
ing and sneezing, because a full inspiration cannot be taken. A slight 
attack of bronchitis may be very serious on this account. On inspec- 
tion during inspiration, instead of the natural expansion of the ribs and 
chest, the epigastrium and the hypochondriac regions are drawn in. 
During expiration they are pushed forward. The thoracic movements 
are reversed. The abnormality may be detected on palpation with 
both hands below the cartilages of the ribs, even better than by inspec- 
tion. Unilateral paralysis of the diaphragm causes drawing in of the 
corresponding hypochondriac region. 

In progressive muscular atrophy, in general lead-poisoning, and in 
multiple neuritis from other causes, paralysis of the diaphragm may 
take place. It is said to occur in hysteria, and Walshe states that he 
has seen it after diphtheria. In fatty degeneration of the diaphragm, 
on account of inflammation extending from the peritoneum to the pleura, 
the same phenomenon has been seen. It may occur in trichinosis. 

Paralysis of the diaphragm must be distinguished from inaction. 
If during the act of inspiration one or both hypochondriac regions are 
drawn in, it is diagnostic of inaction rather than of paralysis ; whereas 
paralysis of the diaphragm is always accompanied by paralysis of other 
muscles. 

Dyspnoea due to paralysis of other respiratory muscles can be recog- 
nized on careful inspection and palpation. The atrophied groups of 
muscles are readily observed. Electricity may aid in the diagnosis. 

2. Pain inhibits muscular action. The source of the pain may be 
in the pleura, the muscles, or the intercostal nerves. Frequently it is 
below the diaphragm, as in peritonitis, hepatitis, etc., interfering with 
the action of that muscle. The dyspnoea that occurs from pain, as 
pleuritis, or inflammation of the chest-wall, is recognized by the posture 
which is taken in order to relieve the affected side, by local tender- 
ness, and by the physical signs of pleurisy or of pleurodynia. 

Clinical Varieties. We observe whether dyspnoea is (a) influenced 
by exertion ; (b) modified by the frequency of respiration ; or (c) by 
the respiratory rhythm ; and (d) is constant or paroxysmal. 

(a) Influenced by Exertion. 1. Shortness of breath may be 
apparent on exertion only, as in cases of simple debility, or of inter- 
ference Avith respiratory action on account of obesity. It is the form 
of shortness of breath seen in anaemia and in moderate cardiac debility. 
It may not be observed by the patient unless he walks hurriedly or 
ascends a flight of stairs. 2. Shortness of breath independent of exer- 
tion is of more serious import, and is due to a number of causes. It 
is the shortness of breath that is seen in severe cardiac and pulmonary 
disease. To the latter belong asthma and emphysema, bronchial ob- 
>t ruction, pulmonary consolidation and compressions (by effusions). 



DISEASES OF THE LUNGS AND PLEUBM. 4G3 

(b) The Frequency of Respiration. Dyspnoea varies clinically 
in the frequency of the respiration. In its most extreme form it is 
known as orthopnoea, when the upright posture of the trunk is assumed. 
(See Posture.) 

1. Respiration Slow or Normal, a. Dyspnoea may be characterized 
by deep inspirations, the frequency of respiration being less than nor- 
mal. This is one of the forms of dyspnoea seen in diabetic coma — 
" breathlessness without dyspnoea." It is most characteristic, and 
associated with nausea, vomiting, and coma, while the breath and urine 
smell of acetone, b. The breathing may be slow and stertorous. Such 
breathing is likewise associated with coma, but the coma is of central 
origin, due chiefly to apoplexy or tumor. It may be observed that 
respirations with dyspnoea are usually central or toxic. 

Toward the end of life the respirations, even though hurried before, 
become slower from carbon dioxid intoxication. 

2. Respirations Increased. The respirations may be hurried and 
create distress in simple nervousness alone, and hurried respiration is 
quite common in cases of hysteria. In the latter affection the frequent 
breathing is often attended by distress. The respirations are quick- 
ened, and are half the normal pulse-rate or even as frequent as the 
pulse. The term " panting" is applied to such respiration. The same 
character of breathing is seen in exophthalmic goitre. The rate of 
respiration is increased in all forms of dyspnoea upon exertion (see 
above), and in all forms due to heart or lung disease. 

(c) The Rhythm. Alternately slower and shallower breathing, and 
then quicker as well as deeper, is seen in the peculiar form of breath- 
ing known as Cheyne-Stokes respiration. It includes a period of 
apnoea, with simultaneous alterations in the size of the pupils. (See 
Uraemia and Diseases of the Brain.) 

(d) Dyspnoea may further be divided clinically into constant and 
paroxysmal dyspnoea. Constant dyspnoea implies a persistence of the 
cause. Paroxysmal dyspnoea does not include the form that is in- 
creased by exertion — a form which in one sense may be paroxysmal. 
It is seen in its most typical form in asthma. It is often of cardiac 
origin, but may be due to central or reflex causes. It occurs usually 
at night. Constant dyspnoea is frequently subject to aggravations 
paroxysmal in occurrence. Asthma is the type of true paroxysmal 
dyspnoea. 

Diagnosis. While dyspnoea is usually easy of recognition, it must 
not be forgotten that attacks of acute indigestion, with thoracic symp- 
toms of oppression, may simulate the oppression of dyspnoea. This 
form of dyspnoea is temporary, however, and not associated with in- 
creased rapidity of respiration. Dyspnoea is recognized by increase in 
rapidity of chest-movement, with increased action of all the muscles 
of respiration, both the essential and the auxiliary muscles. At the 
same time the expression is characteristic. The alee nasi move, the 
eyes and countenance are indicative of more or less agony, the pupils 
are dilated. As the dyspnoea continues cyanosis develops, and fre- 
quently a cold sweat breaks out. This may be limited to the forehead 
and face and to the extremities, or may become general. The hands 



464 SPECIAL DIAGNOSIS. 

and feet become cold. Stupor sets in, carpo-pedal spasm or general 
convulsions follow, the respirations become slower, and death takes 
place in coma or from heart-failure (asystole). 

The dyspnoea of emphysema is characteristic ; it is due to inability 
to empty the chest of air {expiratory dyspnoea). The inspiration is 
short and quick ; the expiration is prolonged, and all the auxiliary 
muscles are called upon to complete the act. The powerful abdominal 
muscles are seen to contract vigorously, and thus aid in pressing up 
the diaphragm. The quadratus lumborum and serratus posticus supe- 
rior et inferior draw down the ribs. The scaleni are strongly con- 
tracted, the serratus magnus, latissimus dorsi, and the pectorales all 
aid in elevating the ribs. Knowledge of the processes involved in 
forced expiration renders the diagnosis comparatively easy. The con- 
traction of the broad abdominal muscles confirms the diagnosis. 

Cough in Pulmonary Affections. (See Larynx.) Coughing is a 
reflex act. A deep inspiration is taken, followed by closure of the 
glottis, succeeded immediately by a sudden expiratory effort, during 
which the glottis is opened, causing a loud sound with the forcible 
passage of air outward, along with any substances in the air-vessels. 

Causes. The pulmonic irritation, on account of which the act takes 
place, usually begins in the respiratory mucous membrane. The cough 
is then used to expel accumulations of mucus or pus, or foreign sub- 
stance. It occurs in all forms of bronchitis and in the lung affections 
generally in which bronchitis is associated. The cough of phthisis, if 
not laryngeal, is due to a localized bronchial catarrh. Nodules outside 
of the bronchi, situated in the lung substance, do not provoke the act 
of coughing, as we see in the calcareous and fibrous nodules of healed 
tuberculosis. The irritation is not limited to the mucous membrane 
of the bronchial tubes, but occurs in the mucous membrane of any por- 
tion of the respiratory tract. A foreign body of any kind in the 
bronchus sets up cough. It is notably present in pharyngeal and 
laryngeal diseases. The cough of the latter is of peculiar character, 
Avhich renders it easily distinguished from cough due to other causes. 

It must not be forgotten that the presence of an irritant does not 
always excite cough. Thus, when the sensibilities are obtunded, as 
in typhoid fever, in disease of the brain, or in the last stages of any 
disease, the presence of mucus will not excite cough, and yet it is 
known to be in the trachea, on account of the rattling which takes 
place. In cases of phthisis sudden checking of the cough and expecto- 
ration, on account of weakness, is of bad prognosis and denotes ap- 
proaching death. It is also a bad sign in pneumonia. 

Central and Reflex-cough. Cough may also occur from 
causes outside of the air-passages. It may be of centric origin. Kohts 
has found by experiment that irritation of the floor of the fourth ven- 
tricle, above the centre for respiration, excites a cough. This centric 
origin may possibly explain the cough of hysteria, and the short, bark- 
ing cough which arises in hysterical or nervous states, when the patient 
i.< afflicted with the idea that he is about to have hydrophobia. Irrita- 
tion of nerves which are in anatomical relation with the pneumogastric 
also excites cough. 



DISEASES OF THE LUNGS AND PLEURAE. 465 

Ear-cough. The most characteristic cough of this form is that 
due to the presence of a foreign booty in the meatus of the ear, or to 
disease of that organ. It is sometimes difficult to examine the exter- 
nal auditory meatus, because coughing is excited. The afferent nerve 
which' receives the irritation is the auriculotemporal branch of the 
fifth nerve, according to Dr. Fox, and not the minute auricular twig 
of the vagus. 

Tooth-cough. The same authority points out the occurrence of 
cough from the irritation of the stump of a tooth, and refers to cough 
in infants during the first dentition. 

Stomach-cough. The popular opinion that cough is very fre- 
quently due to the stomach is not substantiated by the experiments 
of Kohts. Nevertheless, Ave frequently observe cough in patients who 
are suffering from mild gastric catarrh, the treatment of which relieves 
the cough. This is in all probability due to the fact that with the gas- 
tritis there is a secondary pharyngitis, and, as the former is relieved, 
the latter, which causes the cough, disappears entirely. 

It will be seen, therefore, that when investigating the cause of a 
cough in diseases in which this symptom is prominent, it is necessary 
not only to make examination of the respiratory tract throughout its 
course, but also to examine the condition of the ears and the teeth, 
and to bear in mind its possible centric origin. 

Clinical Characteristics. The cough may be dry or moist. A 
dry cough occurs when there is an irremovable source of irritation 
(see dry cough of laryngeal disease). It is seen in the first stage of 
bronchitis. It occurs in the earlier stages of phthisis. As a short, 
hacking, suppressed cough it occurs in pleurisy in the first stage. In 
the second stage it is superficial, as if the sound-waves were checked. 
It is characteristic and most familiar, although described with diffi- 
culty. It is the best type of cough due to irritation outside of the 
respiratory tract. The ear-cough and tooth-cough partake of this char- 
acter. In cases of emphysema the cough may be dry and unproduc- 
tive for a long time, and only be relieved after a small pellet of tough 
mucus is discharged. In the same category belong the nervous cough, 
which is nothing but a bad habit; the cough of hysteria, and the cough 
of a peculiar barking character that occurs at puberty, which Sir 
Andrew Clark has described. 

The moist cough is attended by expectoration of a mucus, muco- 
purulent, purulent, or bloody character, which is comparatively easily 
removed. 

Dry and moist or loose cough may be either constant or paroxysmal, 
or both. Constant cough implies a persistence of the cause, which is 
strictly pulmonary, as in pleurisy, phthisis, bronchitis, and consolida- 
tions generally ; paroxysmal, a recurrence of cause when pulmonary, 
or a reflex or central cause. 

Under some circumstances the cough is almost constant. The irri- 
tation is constantly present. A large amount of secretion is rapidly 
poured out, keeping up a constant cough. This is seen in bronchorrhoea 
and bronchial dilatation and in the later stages of tuberculosis. In 
these affections the moist cough may occur three or four times in 

30 



466 SPECIAL DIAGNOSIS. 

twenty-four hours, during which time an enormous amount of sputum 
is thrown off. The cavity is thereby emptied, the accumulation of 
matter in which excites coughing only after a certain level is reached. 
In this affection the cough is further characterized by aggravation on 
change of position. 

The moist cough may occur in paroxysms only, each paroxysm being 
relieved by the removal of the irritation, the subsequent paroxysm 
not taking place until the irritating secretion has reaccumulated. In 
cases of bronchitis of the second stage paroxysms of cough may occur 
every few hours, or the cough may take place once in the twenty-four 
hours, usually in the morning on arising. The accumulated secretions 
of the night are disposed of, and then the patient remains free from 
annoyance. Paroxysmal coughs occur in cases of cavities, either of the 
lung or of the pleura opening into the lung. Cough is excited when- 
ever the cavity fills with secretion. The paroxysm may occur daily 
or several times a day. The association with retching and vomiting 
is of some diagnostic significance. It is seen not only in whooping- 
cough, but also in phthisis. In pertussis the character of the cough is 
of special diagnostic significance ; it occurs in paroxysms. The expira- 
tory efforts are frequent and rapid, followed by a noisy, prolonged 
inspiration, during which the characteristic whoop is created. At the 
same time the appearance of the countenance is marked. The face is 
cyanosed, the eyes stare, the appearance of distress is most striking. 
The labored efforts at coughing frequently terminate in an attack of 
retching or vomiting. 

The diagnostic significance of cough is estimated by the character ; 
by the sound ; whether constant or paroxysmal ; by the frequency of 
the paroxysm ; by its development at particular times or under partic- 
ular circumstances, as on arising in the morning, or change to a cold 
atmosphere, or speaking, or upon movement, as in phthisis. By the 
sound, laryngeal and bronchial, coughs are distinguished. The diag- 
nostic value of cough further depends on a knowledge of its duration 
and the character of the expectoration. (See Sputum.) 

The Sound. The character of the cough sound, however, is usually 
modified by the condition of the larynx, for which consult the section 
on Laryngeal Diseases. 

Hemorrhage. Hemorrhage of the lungs occurs from disease or 
from rupture of adjacent bloodvessels into the air-passages. It is not 
in itself a symptom of lung disease. A hemorrhage may be small in 
amount and continue over a considerable period of time, or it may be 
characterized by a sudden profuse discharge, which at once terminates 
the life of the patient. 

Cause. A. Affections of the lungs. 

1. Congestion of the lungs will lead to hemorrhage. The amount of 
blood is small ; it may be limited to streaking of the expectoration, or 
a few mouthfuls may be discharged. In (a) organic heart disease this 
form of hemorrhage is seen. It is also a characteristic feature of 
the first stage of (6) croupous pneumonia. The rusty-colored sputum 
is due to the rupture of the capillaries. In (c) hemorrhagic infarcts 



DISEASES OF THE LUNGS AND PLEURA. 467 

hemorrhage occurs, and is diagnostic if attended by the sudden forma- 
tion of a consolidated area in the lung. In (d) phthisis it also occurs 
(see below). 

2. Tuberculosis. In tuberculosis hemorrhage may occur either («) 
as the first symptom of the disease, on account of collateral conges- 
tion around infiltrated areas, or (6) later, on account of ulceration of 
an artery when excavation of the lung has taken place. In the early 
stages the hemorrhage is usually profuse, but not fatal. It may 
occur repeatedly during a series of weeks, excited, no doubt, by the 
violent non-productive cough which attends the earlier stages of this 
disease. In the later stages, when the vessels are ulcerated, the patient 
may have repeated hemorrhages, varying from a few ounces to half a 
pint or a pint. They may occur daily, or be repeated at intervals of 
a week or more for a long period of time. After the hemorrhages that 
occur at long intervals the patient experiences much relief. Indeed, 
the dyspnoea, cough, and chest oppression subside in a remarkable 
degree, and the occurrence of another hemorrhage is often predicted 
by a gradual recurrence of these symptoms. Death does not usually 
ensue on account of the large hemorrhage from phthisical ulceration, 
and yet it may possibly take place. The writer has seen four instances 
of hemorrhage into a large cavity, three with external hemorrhage, 
which caused death instantly. Hemorrhage with the expectoration of 
calcareous masses recurs (c) frequently in patients with healed or qui- 
escent tubercle. 

3. Cancer. Hemorrhage recurring frequently is significant of can- 
cer of the lungs, in the absence of other causes. 

4. Plastic Bronchitis. It is of common occurrence in plastic bron- 
chitis, when large bronchial casts are expelled. 

5. Gangrene. In gangrene of the lung it frequently occurs, often 
causing death. The odor and sputum indicate the true nature of the 
primary lesion. 

B. Disease outside of the respiratory tract. (1) Aneurismal disease 
of the bloodvessels, which are in intimate relation with the trachea and 
bronchus, frequently causes ulceration into these tubes, with hemor- 
rhage. The hemorrhage is usually profuse and often induces sudden 
death. Sometimes the profuse hemorrhage may be preceded for days 
by small hemorrhages. The physical signs of aneurism are sufficient 
to explain the cause. The bleeding can sometimes be seen in the 
trachea, when an aneurism of the innominate artery or the aorta presses 
upon that tube. (2) In diseases of the heart it does not usually take 
place until the later stages of the disease, and is associated with second- 
ary congestion of the lungs. It may, however, be an early symptom 
in mitral stenosis. The hemorrhages may amount onlv to staining of 
the sputum, or several times during the day an ounce or more of blood 
may be expectorated. 

C. Affections of the blood or bloodvessels, with hemorrhages in 
other portions of the body. Thus, it may occur in haemophilia, in 
purpura, in scurvy, and in anaemia. It occurs in jaundice with hemor- 
rhages in other situations. 



468 SPECIAL DIAGNOSIS. 

D. Gouty endarteritis. In the aged of both sexes, hemorrhages 
take place independently of disease of the heart or of the parenchyma 
of the lungs. Sir Andrew Clark and others have spoken of these 
hemorrhages and attributed them to gouty changes in the vessels as 
well as to degenerations of lung-tissue, on account of which the rap- 
ture took place. 

E. Without known cause. In certain instances pulmonary hemor- 
rhages occur in which it is quite difficult to find any cause for the dis- 
charge. It is quite common to see hemorrhage occur in females : some- 
times at the menopause, in other cases during menstruation, or, again, 
perhaps vicariously, when menstruation does not occur. A number of 
cases that have come under the writer's observation have had this ten- 
dency for years without the development of pulmonary disease, and, 
apparently, without much influence on the general health. Indeed, it 
may be said that recurrent hemorrhage from the lungs in women, in 
the absence of organic disease, is not of grave significance. 

The Symptoms. The only symptom may be the presence of blood 
hi the expectoration, or the discharge of a small amount of blood with 
slight cough. In either instance, unless the patient's mental condition 
is rendered obtuse by disease, the hemorrhage is alarming to him. He 
is much perturbed, and there may be palpitation of the heart, besides 
other nervous phenomena. Apart from the nervousness excited by 
the sight of blood, small hemorrhages, and even hemorrhages of mod- 
erate amount, do not cause any other symptoms. 

The symptoms of a large hemorrhage depend upon the amount of 
blood that is lost. They may amount to faintness and giddiness only, 
Avith or without pallor. If more pronounced, syncope may take place ; 
extreme pallor develops ; the pulse becomes rapid, small, and feeble ; 
the extremities are cold, and the face bathed in perspiration. If the 
patient recovers from the syncope, he is extremely restless, sighing and 
breathing hurriedly. There may be some nausea. Moderate delirium 
and mild febrile symptoms often follow the restlessness. If the hem- 
orrhages do not recur and the patient's fears are calmed, the color will 
gradually return and the heart's action become stronger and slower. 
These symptoms occur whether the hemorrhage is due to disease of the 
lungs or to aneurism rupturing into the bronchus. If the hemorrhages 
are large, they differ somewhat in the two conditions. If a large aneu- 
rism ruptures, the blood rapidly wells up into the throat and pours out 
through the nostrils and mouth with great rapidity. With such hem- 
orrhage the end may come in a few minutes. In pulmonary hemor- 
rhages the discharge is not so profuse, and is attended by coughing. 
With each cough blood is raised to the amount of a full mouthful at a 
time. The blood discharged from the lungs is bright in color, very 
frothy, being mixed with air. There are no clots in the discharged 
fluid. The blood from an aneurism is also bright red, but is not frothy, 
unless the discharge is very slow, and becomes mingled with air in the 
vessels. In rare cases of pulmonary hemorrhage an abundant stream 
pours out, which is dark in color, free from clots, and not mixed with 
air (large cavity). 



DISEASES OF THE LUNGS AND PLEURjE. 469 

Diagnosis. Hemorrhage from the lungs must be distinguished from 
hemorrhage from the upper air-passages, the mouth, the stomach, and 
oesophagus. Thus a discharge of blood from the mouth may occur 
from cracks in the pharynx, or varicose veins. It is not abundant, 
and the hemorrhage is mingled with mucus, which is streaked with 
blood. Hemorrhage from the gums may be taken for pulmonary hem- 
orrhage, unless there is stomatitis, or inflammation of the gums from 
scorbutus or ptyalism. In stomatitis its color is somewhat different. It 
is thin, fluid blood, often offensive, of cherry-juice color. Hemorrhage 
from the lungs is distinguished from hemorrhage from the stomach by 
the difference in the way in which it is discharged, and the difference 
in the character of the blood. If from the stomach the blood is vom- 
ited. It is mixed with particles of food or other gastric contents. It 
is dark in color, often of the appearance of coffee-grounds ; it is not 
mixed with air, and hence is not frothy. The rapid hemorrhage from 
ulceration of an aneurism into the oesophagus, or rupture of varicose 
veins at the lower end of the oesophagus, cannot be distinguished by 
the appearance from the hemorrhage of an aneurism which may have 
ruptured into a bronchus. The recognition is dependent upon the 
physical signs and the previous history of the patient's illness. 

Pain. Pain is rarely a symptom of disease of the lungs unless the 
pleura is involved. In a case of bronchitis there may be some sore- 
ness and oppression behind the sternum, but otherwise pain is absent. 

In pleurisy pain occurs before the exudation. It is sharp and lanci- 
nating, and so severe as to impede respiration and cause the cough to 
be short and catchy. It is usually seated at the base of the chest, in 
the lateral or anterior region. It occurs when the patient attempts to 
take a full breath. Before the inspiratory excursion is half completed 
it is checked involuntarily, on account of the pain. The patient's hand 
is placed upon the affected part and he involuntarily leans to that side. 
The pain of pleurisy may be increased by local pressure, but general 
pressure, as from the whole hand, a broad bandage, or a large strap of 
adhesive plaster, always gives relief. In the pleurisy that attends 
phthisis pain is quite common. It is of the same character as the pain 
of acute plastic pleurisy, but varies in situation and in degree. The 
pain occurs in paroxysms. It follows a slight exposure to cold, undue 
exertion, or fatigue. It may continue for twenty-four hours, and dis- 
appear until a repetition of the cause brings it on again. It must be 
distinguished from the myalgia of phthisis due to cough and exposure. 
In myalgia the muscles and fascia? at the bony attachments are very 
tender. 

The pain of pleurisy must be distinguished from pleurodynia, from 
intercostal neuralgia, and from the pain due to the disease of the ribs. 
In pleurodynia the muscles are sensitive if pressed between the fingers 
or palpated. An enlarged area is affected, but physical signs of pleu- 
risy or pneumonia cannot be elicited. Cough is absent, and so, usu- 
ally, is fever. It is associated with pain in other muscular or fibrous 
structures. There may be a previous history of exposure to cold and 
dampness. Usually there is a history of lithaemia or frequent myalgia. 



470 SPECIAL DIAGNOSIS. 

Intercostal neuralgia is sometimes difficult to distinguish. The pain 
is sharp, localized, and may modify the movements of the chest. Gen- 
eral pressure relieves it ; local pressure at the points where the termi- 
nal filaments of the nerve come to the surface may increase it. The 
so-called Valleix's tender points are, however, not always present in 
cases of intercostal neuralgia. The patient is usually anaemic, often 
the subject of uterine or other exhausting disease, and may suffer from 
neuralgia in other situations. Cough and physical signs are absent. 
Fracture of the rib, or caries of the rib, may be recognized by the local 
tenderness and by the signs of these conditions. Localized pleurisy 
may attend both, however — indicated by more severe pain on cough 
or full breathing. Caries or fracture is determined by pressure upon 
the diseased rib, which elicits the crepitus of fracture. An empyema 
that is about to point will cause pain in some area of the chest. The 
pain is usually seated at the points of election for the discharge of the 
empyema, and is soon followed by swelling, with heat and redness of 
the skin, and the occurrence of oedema. 

More or less constant pain at the apices, undoubtedly independent 
of affections of the muscles, is a suspicious sign of tuberculous disease 
in that situation. It may be aggravated by pressure. 

The Data Obtained by Observation. 

The Objective Symptoms. By physical examination of the lungs 
we ascertain (1) their degree of activity (movement) ; (2) the physical 
condition of their parts subjected to examination ; but the disease is not 
diagnosticated. If abnormal signs are detected, they simply indicate 
an abnormal condition of the part, which condition may be clue to any 
number of diseases. As the lungs in health contain air, any physical 
change that takes place causes either an increase or a diminution in the 
amount of air. This may be general (bilateral), or limited to one side 
(unilateral), or to a smaller area (local). In examining the lungs we 
might be content to answer the question, Is there an increased or a 
diminished amount of air in the parts suspected to be the seat of dis- 
ease ? A correct answer to this question, and to an inquiry as to the 
case of the increase or diminution, would explain any abnormal phys- 
ical condition. The answer is determined by percussion. Fortunately, 
however, we have as adjuncts the phenomena that can be elicited by 
means of inspection, palpation, and auscultation. These methods of 
examination depend upon the movements of the lungs and the sounds 
produced in breathing and speaking. 

Value of Inspection and Palpation. Too much emphasis has 
been laid in the past on auscultation and percussion in the study of 
lung diseases. It is the habit to rely too much on these methods, to 
the exclusion of the simpler and quite as valuable methods — inspection 
and palpation. The latter have been employed for a long time in the 
study of the objective phenomena of disease. The former are com- 
paratively modern methods, and have required special cultivation of 
senses not usually employed in observation, in addition to exhaustive 



DISEASES OF THE LUNGS AND PLEUBJS. 47 1 

comparative research, to put the findings on an accurate basis. 
Naturally, they have been given undue prominence as methods of 
diagnosis. The pernicious habit of examining the patient without 
removing the clothing, either from haste upon the part of the physician 
or false modesty upon the part of the patient, has unfortunately also 
led to the neglect of inspection and palpation. It is proper to 
insist that the data obtained by inspection and palpation are as 
important and valuable as those obtained by other means. They are 
even more suggestive or diagnostic of physical conditions. The phe- 
nomena observed are more positive and surrounded by fewer qualifica- 
tions. 

The Regions of the Chest. For the purpose of bearing in mind 
the relations of the organs to the surface of the chest, and the localiza- 
tion and proper recording of the seat of the disease, the chest is divided 
into regions. The regions correspond to anatomical points on the sur- 
face of the chest, and are subdivided by transverse and vertical lines. 
Knowledge of the landmarks which indicate on the surface the position 
of the parts underneath is of great importance in diagnosis. The 
regions in the anterior portions of the chest are : The supraclavicular 
region, above the clavicle ; the infraclavicular region, below the clavi- 
cle, extending to the third rib ; the mammary region, from the third 
to the sixth rib. In the axilla two regions suffice— the upper and 
lower — the position of the disease being more definitely determined by 
association with ribs and interspaces. Posteriorly the regions are 
the suprascapular, above the scapula ; the scapular region, and the 
infrascapular region ; the region between the scapula and the spine is 
known as the interscapular region. The vertical lines are to the 
right and left of the median line : (1) The parasternal line, which is 
drawn downward midway between the edge of the sternum and 
the second line, which is (2) the mid-clavicular line, drawn from the 
middle of the clavicle, generally passing through the nipple in males ; 
(3) the anterior axillary line, drawn from the anterior fold of the 
axilla ; (4) the mid-axillary line, from the centre of the axilla ; (5) 
the posterior axillary line, from the posterior fold of the axilla. In 
the back one line is sufficient — the scapular line, drawn through the 
angle of the scapula when the arm is at rest at the side of the patient. 
For transverse lines the ribs and interspaces are used. In this way 
the exact location of a diseased area can be indicated. In order that 
accuracy may attend its localization, knowledge of the methods of 
determining the landmarks, and especially of counting the ribs, is 
essential. 

The Angles of the Thorax. The costal angle is the angle of 
the rib. It varies during the act of respiration. In inspiration the 
rib rises as the sternum projects, and apparently elongates ; the angles 
become more obtuse ; in expiration the sternum falls, the ribs become 
more slanting, and the angle is more acute. 

The epigastric angle. This angle is formed by the convergence of 
the ribs of both sides to the xiphoid cartilage of the sternum. On in- 
spiration it is obtuse, increasing as the ribs rise ; in expiration it is 
more acute. 



472 SPECIAL DIAGNOSIS. 

Method of Counting Ribs and Interspaces. The first rib 
corresponds to the clavicle ; the first interspace is the region between 
the clavicle, or first rib, and the second rib ; the subsequent number 
of an interspace corresponds to the number of the rib above it. The 
following, from Holden, is of great importance to remember, particu- 
larly when the ribs of fat persons are counted : 

a. The finger passed down from the top of the sternum soon comes 
to a transverse projection, slight, but always to be felt, at the junction 
of the first Avith the second bone of the sternum. This corresponds 
with the middle of the cartilage of the second rib. 

b. The nipple of the male is placed in the great majority of cases 
between the fourth and fifth ribs, about three-quarters of an inch ex- 
ternal to their cartilages. 

c. The lower external border of the pectoralis major corresponds 
with the direction of the fifth rib. 

d. A line drawn horizontally from the nipple round the chest cuts 
the sixth intercostal space midway between the sternum and the spine. 

This is a useful rule for localization in tapping the chest. 

e. When the arm is raised the highest visible digitation of the serra- 
tus magnus corresponds with the sixth rib. The digitations below 
this correspond respectively with the seventh and eighth ribs. 

/. The scapula lies on the ribs from the second to the seventh, inclu- 
sive. 

g. The eleventh and twelfth ribs can be felt, even in corpulent 
persons, outside the erector spina?, sloping downward. 

h. One should remember the fact that the sternal end of each rib is 
on a lower level than its corresponding vertebra. For instance, a line 
drawn horizontally backward from the middle of the third costal car- 
tilage, at its junction with the sternum, to the spine, would touch the 
body, not of the third dorsal vertebra but of the sixth. Again, the 
end of the sternum would be at about the level of the tenth dorsal 
vertebra. Much latitude must be allowed here for variations in the 
length of the sternum, especially in women. 

It is important to recognize the relation of the ribs to the vertebrae. 
The first rib articulates with the first dorsal vertebra, which can be 
located by the position of the prominent spine of the seventh cervical 
vertebra ; even in very fat people this prominence can be recognized. 
The remaining ribs, except the tenth, eleventh, and twelfth, have 
facets of articulation on two vertebra? ; as the second rib, with the 
first and second thoracic vertebra?. The eleventh and twelfth articu- 
late with the eleventh and twelfth thoracic vertebra?. 

Topographical Anatomy. The following anatomical points are 
worthy of remembrance : 

The top of the sternum is on a plane with the lower border of the 
second dorsal vertebra behind. The junction of the first and second 
portions of the sternum is known as the angle of Ludwig. It is oppo- 
site the middle of the second rib, and is on a plane with the lower 
border of the fourth dorsal vertebra. The junction of the body of the 
sternum to the xiphoid cartilage is on a plane with the lower border of 
the eighth dorsal vertebra. 



PLATE XIII. 



Fig. 1. Anterior Aspect. 





Fig. 2. Posterior Aspect. 




Situation of the Viscera. 

Jut lines of heart and vessels-broad red lines. Margins of lungs and oi individual lobes-dotted green lines. 

Limits of pleural sacs-solid green lines. Liver-red shading. Stomach-green shading. 

(In part after His-Spalteholz and Luschka.) 



PLATE XIV. 



Fig. 1. Right Lateral Aspect. 



Fig. 2. Left Lateral Aspect. 





Situation of the Viscera. 



Margins of lungs and of individual lobes — dotted green lines. Limits of pleural sacs — solid green lines. 

Liver and srjleen — solid red lines. Diaphram — dotted red lines. Stomach (portion not 

covered by lung) — green shading. (In part after Luschka.) 



DISEASES OE THE LUNGS AND PLEURAE. 473 

The apex of the diaphragm is on a level with the eighth dorsal ver- 
tebra. 

The trachea bifurcates at the plane which includes the angle of Lud- 
wig and the fourth dorsal vertebra. 

Purulent effusions in the left pleural sac frequently point at the 
fifth interspace, beneath the nipple, because this is the weakest point 
of the chest-covering. A little external to the inferior angle of the 
scapula and the eighth and ninth interspaces a similar weak point is 
found. 

Limits of the Lungs. The apices of the lungs reach three to 
seven centimetres (one and one-fifth to two and three-quarter inches) 
above the clavicles in front ; behind they rise as high as a line drawn 
transversely through the spinous process of the seventh cervical verte- 
bra. The lower anterior margin of the right lung, when the chest is 
passive, commences at the insertion of the sixth rib into the sternum, 
and runs parallel with the upper border of the sixth rib to the axillary 
line. At this point it descends to the upper margin of the seventh rib. 
On the left side the lower limit extends as far downward as the right. 
Posteriorly both lungs reach to the tenth rib. With full inspiration 
the lungs descend both in front and behind almost the extent of one 
interspace, while in deepest expiration they are elevated almost to the 
original position. The u complemental space " of Gerhardt is the space 
at the lower margin of the lung, and at the point at which the left lung 
overlaps the heart, in which, during expiration, the surfaces of the 
visceral and parietal pleura come together. In inspiration the thin 
layer of the lung in both situations insinuates itself into this space. 
The heart interferes with the extension of the left lung. The space 
is triangular in shape, extending in the median line from the fourth to 
the sixth rib. The left edge of the triangular area corresponds to the 
edge of the left lung, which, notched for the heart, diverges from the 
median line and runs along the cartilage of the fourth rib. 

Position of the Lobes. Plates XIII. and XIV. illustrate the 
position of the lobes of the lungs. In the right lung the upper lobe 
in front extends to the fourth rib, in inspiration laterally to the third, 
and behind to the spine of the scapula. The lower lobe begins with 
the spine of the scapula and extends to the tenth rib behind, and from 
the fourth to the tenth ribs, when fully expanded, in the axillary 
region. The middle lobe is not seen behind ; it extends between the 
third and fourth ribs in the axillary region in inspiration. In front it 
extends from the lower margin of the upper lobe to the sixth rib. 

The upper lobe of the left lung extends to the sixth rib in front and 
to the fourth interspace at the side. Behind, a small portion extends 
above the spine of the scapula, while the lower lobe extends from the 
spine of the scapula to the base of the lung behind. At the sides it 
extends from the lowest limit of the upper lobe to the level of the 
eighth rib. 

Inspection. By inspection we learn (1) the appearance of the ex- 
ternal surface, (2) the shape and size, and (3) the movements of the 
chest. The second indicates the capacity of the lungs ; the last, the 



474 



SPECIAL DIAGNOSIS. 



degree of functional activity. The X-rays are also employed to con- 
duct inspection. 

Methods. The patient must be seated, if possible, in an easy 
position, with the light falling directly on the part or from the side. 
He should be viewed by the observer standing, first in front, then be- 
hind, and also from the side. To observe the anterior portion it is 
often well to stand behind the patient and look downward over the 
shoulders. The arms should fall by the side ; the breathing should be 
quiet and undisturbed by talking or unusual movements. 

The Skin and Subcutaneous Tissue. In health the normal 
covering should be supple, elastic, and of the color previously described. 
It is pale in ansemia and wasting diseases ; yellow in jaundice ; pig- 
mented generally or locally from causes previously mentioned. It is 
the particular seat for the parasitic disease, tinea versicolor, and is the 
seat of sudamina as well as other non-specific eruptions. The veins 
over the surface of the chest should not be very distinct. They are 
distinct when there is interference with the circulation in the mediasti- 
num from the pressure of an aneurism or morbid growths obstructing 
the veins. They, along with the cervical veins, may also be enlarged 
in dilatation of the right heart. The capillaries along the base of the 
chest are often enlarged or more distinct than usual, and arranged in a 
bow corresponding to the attachment of the diaphragm. This bow 
is frequently seen in intrathoracic obstruction. CEdema or subcutane- 
ous emphysema occurs as indicated under general inspection. If there 
is too much fat over the surface of the chest, the muscles may be want- 
ing in tone, and an estimation, therefore, of respiratory capacity cannot 
be made. Wasting of the fat and muscles is seen in phthisis, carci- 
noma, diabetes, muscular atrophy, and paralysis. The degree of soft- 



Fro. 121. 




Transverse section of healthy adult chest upon level of sterno-xiphoid articulation. 
Circumference = 89 centimetres. 



ness of the ribs can be estimated in a measure by the undue depression 
of the ribs at the costo-cartilaginous articulations, and at the base of 



DISEASES OF THE LUNGS AND PLEURjE. 



475 



the chest (about the sixth rib), during the act of inspiration. It is an 
indication of rickets. Rigidity of the thorax, equal to the senile fixa- 
tion, occurs in some adults in middle life, and Roberts points out that 
in young subjects it may be due to congenital syphilis. 

The Shape and Size of the Chest. We appreciate the shape of 
the chest in health by an estimation of the relations of the antero-pos- 

FlG. 122. 




Transverse section of healthy male adult chest. Semi-circumference, right side, 16% inches ; 
left side, 16% inches ; expansion, 3% inches. (Ward 6, Philadelphia Hospital.) 

terior and the transverse diameters and by the shape of the transverse 
section of the chest. The latter is an ellipse, and has been described 

Fig. 123. 




Transverse section of an infant's chest, aged nine months. A circle within shows the similarity. 



as reniform (see Fig. 121). The antero-posterior diameter is about 
one-fourth less than the transverse. Measurement with the cyrtometer 



476 SPECIAL DIAGNOSIS. 

(see Mensuration) verifies the result of inspection with mathematical 
precision. In children the transverse section is different. It is more 
circular, and the antero-posterior and transverse diameters are almost 
equal. (See Fig. 123.) Marked deviations from such section, or in 
the relations of the diameters, are seen in abnormal types of chest. 

It is difficult to describe the shape of the chest in health. By re- 
peated practice we readily form a judgment of the true shape. No 
rule has been applied to the relation of the length of the chest to the 
length of the body, but it would seem that there is some such propor- 
tion. (See Mensuration.) In health the chest should be symmetrical, 
the right side probably a little larger than the left. In the ideal chest 
the muscles of respiration should be well developed and there should 
be a moderate amount of subcutaneous fat. The sternum should pro- 
ject forward from above downward, and the portion joining the manu- 
brium and the gladiolus should be a little more prominent than the 
other part. It is not unusual to see a clearly marked demarcation 
between the upper and middle portions of the sternum, or an undue 
projection of one or more of the upper ribs, and some striking changes 
about the xiphoid cartilage, none of which are indications of disease. 
The xiphoid may be depressed, on account of which a crater form or 
funnel-shaped depression is seen (occupation). The tip of the cartilage 
is sometimes drawn inward, but more frequently the reverse is noted. 

The Movements of the Chest. The frequency, the rhythm, the 
degree of expansion, and the so-called diaphragm-phenomena are 
studied. A complete respiratory act consists of two events, inspiration 
and expiration. Inspiration is active ; expiration passive. The latter 
act is a trifle longer than the former, as may be illustrated by the 
following proportion — Insp. : Exp. : : 5 : 6. A pause follows the act 
of expiration. The chest increases in circumference and in vertical 
length (descent of diaphragm) in inspiration as the lung expands with 
air. The term expansion is applied to the result of inspiration ; its 
degree varies. 

The frequency and character of the movements in health vary in the 
two sexes. The respirations are from 16 to 24 in the minute in a 
healthy adult. In the female they may be 20 to 22. In children the 
frequency of respiration is much greater — under one year, 44 per 
minute, and at five years 26. They are increased in frequency in the 
standing position. They are lessened in the horizontal position, in- 
creased during bodily exertion, with increased temperature of the air, 
and during digestion. The hand placed on the epigastrium facilitates 
counting of the respirations. 

The movements of the chest in quiet breathing are more marked in 
the lower half in male adults, and thus the costo-abdominal or dia- 
phragmatic type of breathing is seen. The sternum rises, the ribs are 
elevated, and at the same time are drawn forward and outward. The 
antero-posterior and vertical diameters increase. The costal angle and 
epigastric angle become more obtuse. The diaphragm acts conjointly 
with the external muscles of the thorax, and, as it descends, the epi- 
gastric region swells with each inspiratory effort. In expiration the 



DISEASES OF THE LUNGS AND PLEUBJE. 477 

sternum falls, the ribs become more slanting instead of horizontal, the 
epigastrium retracts, the angles become acute. The antero-posterior 
and transverse diameters lessen. The upper half of the chest moves 
more actively in women, and hence the costal or upper thoracic type of 
breathing is seen. The areas below the clavicles and the upper por- 
tion above the sternum swell more distinctly during inspiration. The 
movements of the lower portion, and especially of the diaphragm, are 
limited. 

The costal type occurs most frequently in children. The type of 
breathing is costal in both sexes during sleep ; the same type is ob- 
served during deep respiration. 

The Diaphragm-phenomena (Litten). The diaphragm and walls of 
the thorax approach each other during expiration, and come in apposi- 
tion at the end of this act. During inspiration they become separated. 
In persons whose chest-walls are not too thick the movements of the 
diaphragm are indicated on the surface by the rise and fall of a 
shadowy line. The patient must lie on his back with his face from 
the light and head slightly elevated. The light should fall from 
behind. The observer stands a distance of three or four feet with his 
back to the light. The chest is scanned at an angle of about forty- 
five degrees. In the act of inspiration a horizontal shadow or undula- 
tion is seen to start on either side about the sixth interspace and 
passes downward during inspiration over a distance of two or more 
interspaces, and even to the margin of the ribs. In expiration the 
shadow begins below and moves upward to the starting-point. 

Absence of the phenomena is noted when there is fluid or air in the 
pleural cavity, when the pleural cavity is obliterated by adhesions, 
when there is pneumonia of the lower lobe ; and in emphysema of the 
lungs, and intrathoracic tumors low down in the chest. Tumors or 
fluid accumulations below the diaphragm do not lessen the phe- 
nomena. 

By this phenomena the volume or vital capacity of the lungs can be 
estimated. In normal individuals the shadow should move more than 
two and a half inches. If there is lessening of the extent of move- 
ment the respiratory capacity is diminished. In this manner tubercu- 
losis may be suspected. Limitation of the excursion of the diaphragm 
— X-ray investigations have forcibly taught us — is one of the earliest 
signs of tuberculosis. This limited excursion can be detected in proper 
subjects by Litten's method, although it must be remembered that 
general debility and emphysema lessen the excursion on both sides. 
In splenic and hepatic enlargements the normal shadow continues, but 
in a large collection of ascitic fluid it may be detected with difficulty, 
or may be absent. 

The Shape and Size of the Chest in Disease. The chest may 
be enlarged or diminished in size. Such change may be general or 
bilateral, unilateral or local. 

General or Bilateral Changes in Shape. Enlargement The 

u barrel-shaped " chest, the type of bilateral enlargement of the chest, 

is seen in health Avhen it is in the state of full inspiration. All the 



478 



SPECIAL DIAGNOSIS. 



diameters are increased, particularly the anteroposterior ; the length 
is shortened. The diameters are almost equal, and the transverse sec- 
tion approaches a circle. This occurs because in all figures of fixed 
length, in order that the area may be increased, a change to a circular 
form must take place. (See Figs. 125 and 126.) The ribs are ele- 
vated and almost horizontal, the epigastric angle is obtuse. The ster- 
num and the spine are arched ; the former at the angle of Ludwig. 
The shoulders are rounded and elevated, and the scapula? lie flat against 
the thorax. All the muscles of respiration stand out prominently, the 



Fig. 124. 




Emphysema with enlargement of the chest. The antero-posterior diameter is much increased. 
(Ward 6, Philadelphia Hospital.) 



neck and upper trunk muscles particularly. The individual with 
bilateral enlargement of the chest presents a striking appearance. The 
neck is short, the arms are short ; there is undue fulness above the 



DISEASES OF THE LUNGS AND PLEURA. 



479 



clavicles. As this enlargement is attended with dyspnoea, the face is 
drawn and anxious, and the lips usually faintly livid, or purple. 



Fig. 125. 




Bilateral enlargement of emphysema. 
Inner line = emphysematous chest. 
Outer line = a circle drawn to show how nearly the emphysematous 

approaches the circular shape. 
Dotted line = natural adult chest. 



A dual measurement in centimetres. 



Circumference 

Transverse 

Antero-posterior 



natural 89.0 
29.6 
22.25 



emphysematous, 87.75. 
27.25. 
25.4. 



-(Dr. Gee.) 



The movement of the chest in bilateral enlargement. Expansion is 
lessened. The respiratory capacity is diminished. The chest is in a 
state of full inspiration, and the attendant dyspnoea is known as expi- 
ratory dyspnoea. The respirations are hurried, the inspirations short, 
followed by prolonged expiration. While the expansion of the chest 
in health extends over an area of three or four inches, when the chest 
is bilaterally enlarged it may be lessened to one and a half inches, or 
even be as low as half an inch. Both the costal and the diaphragmatic 
types of breathing are seen in a state of exaggeration. In men the 
diaphragm acts very vigorously at times. Expiration is three or four 
times as long as inspiration. 

Cause. The increase in size is due to enlargement of the normal 
contents of the chest or to the presence of abnormal contents. In 
nearly all cases it is due to an increased amount of air within the 
thorax (normal contents), as in emphysema. In a few instances en- 
largement of both sides is seen in cases of bilateral pleural effusion ; but, 
as considerable effusion would be incompatible with life, the enlarge- 
ment from this cause is never very great. It is said that such enlarge- 
ment may occur in rapidly growing cancer of the lungs. 



480 



SPECIAL DIAGNOSIS. 



It mast be remembered that emphysema can exist without bilateral 
enlargement of the chest. 

Bilateral Diminution in Size. The type is seen in the so-called 
phthisical or tuberculous chest. The chest is long, the antero-posterior 
diameter small (see Fig. 126), the transverse relatively very much in- 
creased. The angles are acute, the ribs are slanting, the epigastric 



Fig. 126. 




The flat oi phthisical chest, short antero-posterior, long transverse diameter. (Gee ) 



angle is particularly sharp. The shoulders fall, and hence the scapulae 
are prominent — so marked in many cases that the term alar or 
"winged" chest has been given to it. The anterior plane is often 
flattened, and hence the term ' ' flat " chest is employed. This change 
occurs because the curve in the cartilage of the true ribs becomes 
straight. The movement or expansion is lessened just as the respiratory 
capacity is diminished. 

With this type of chest we see the neck long, the larynx (Adam's 
apple) very prominent, the arms long. -The patient is loosely put 
together ; the length of the long bones is increased. 

It is known as the phthisical, phthisinoid, or tuberculous chest. (See 
Figs. 126 and 127.) Although the term tuberculous is applied to the 
chest of this description, it does not necessarily imply that an individual 
with such a chest has, or will have, tuberculosis. It is true that in 
individuals with such type of chest the vulnerability to the action of 
the tubercle bacillus is more marked, and they are more liable to have 
the disease. Nevertheless a very large number of individuals go 
through life with such chests and die of other diseases. If they are 
not exposed to the infection, they will certainly escape the disease. 

Cause. Bilateral diminution means diminution of contents. The 
extent of air-surface is lessened. 

The Chest of Rhachitls. Another type of diminished size of 
chest is constantly referred to. It is known as the chest of rhachitis 
(see Fig. 129), and arises in infancy, on account of this disease of 
the bones. Many other shapes are seen, to which various names have 
been given. Among the more common is what is known as the 



DISEASES OF THE LUNGS AND PLEURJE. 



481 



" pigeon-breast." (See Rhachitis, and The Head.) The chest is 
usually shortened, the sternum is much more prominent than in health, 
the lower portion projecting to an unusual degree. The portion of 
the chest at the junction of the cartilages and the ribs is depressed. 
This tends to throw the sternum further outward. The transverse 
section of such chest resembles a triangle with the portions where the 
base-line joins the ribs rounded. (See Fig. 131.) The sternum is de- 



FlG. 127 



Fig. 128. 




i 



' ' " y i 



I 





The phthisical chest. (Full-blooded Indian, Philadelphia Hospital. 



pressed and the osteo-cartilaginous articulations are more prominent in 
some forms of rickety chest. In others the ribs and sternum from 
above to the fifth rib are prominent, and from thence downward to the 
base are drawn in. In the chest of rhachitis the costal anole is usually 



very acute. (See Fig. 130.) 
hands, had been applied 



It often looks as if pressure, as by the 



to the sides of the chest about the anterior 
31 



482 



SPECIAL DIAGNOSIS. 



axillary line, causing the anterolateral portion to sink inward, while 
the antero-meclian portion is projected forward. 



Fig. 129. 




Transverse section of a rhachitic chest at level of sixth thoracic vertebra. 
32% inches ; right half, 16% inches; expansion, 2 inches. 



Circumference, 



The chest of rickets is attended by enlargement of the articulations 
of the cartilaginous and bony portions of the rib — the rhachitic rosary 
— and by changes in the other bones. 



Fig. 130. 



Fig. 131. 



'-"; 



J 



7 




Chest of rhachitis. (Eichhokst ) 



Circumference = 42.75 centimetres. 
Rickety chest. Dotted line indicates the shape of 
chest in an infant about the same age. (Gee. ) 



The rhachitic chest must not be confounded with similar changes in 
shape due to abnormal conditions of the upper respiratory apparatus 
in early childhood. In cases of adenoid disease of the pharynx (see 



DISEASES OF THE LUNGS AND PLEURAE. 



483 



Diseases of the Pharynx) the change in shape of the chest has been 
noted. 

The Transverse Groove. This is a depression observed in many 
individuals. It extends from the median line along the base of the 
thorax to the axilla ; its upper limit is on a level with the xiphoid 
cartilage. It slopes downward toward the axilla. It is caused in early 
life by the pressure of the external columns of air on the soft bony 
thorax when the lungs are not completely filled with air. Hence, it 
indicates nasal, faucial, or bronchial obstruction in early life, from 
adenoid disease, bronchial catarrh, or other causes. It may mark the 
upper limit of the liver on the right side as it was in infancy. 



Fig. 132. 




""i£S 

Unilateral enlargement of chest (right side), artificially produced by injecting air into the right 
pleural cavity. Unbroken line : outline before injection. Broken line : outline after moderate 
distention. Dotted line: outline after extreme distention. Figures at bottom of vertical line 
indicate the antero-posterior diameter; along horizontal line, transverse semi-diameter ; remain- 
ing figures, right and left semi-circumference?. (Gfe.) 



The shape of the chest just described (rhachitic) does not indicate 
any disease of the lungs ; it does indicate deficient respiratory capacity, 
and is, of course, the tell-tale by which rhachitis of early life or early 
laryngeal and nasal obstruction are recognized. 

Deformities. The rhachitic chest mast not be confounded with 
deformities of the chest which may be congenital in origin, the result 
of occupation (shoemaking), or of vertebral disease (Pott's disease). 
The funnel-breast (trichterbrust) is congenital and often seen in several 
members of a family (Warthin). It is associated with other stigmata 
of degeneration. The lower sternum forms a deep concavity. (See 
Fig. 133.) 

Unilateral Changes in Shape. Unilateral Enlargement. This 
can usually be seen more prominently at the base. The length is in- 
creased. The ribs are elevated, the side more rounded, the costal 
angle more obtuse. The interspaces are frequently effaced, or fuller 
than on the corresponding side. The movement may be increased or 



484 



SPECIAL DIAGNOSIS. 



diminished, depending upon the cause. The nipple is diplaced out- 
ward. The scapula of the affected side is also displaced outward, and 
hence the distance from it to the spine is greater than on the opposite 
side. (See Fig. 132.) 



Fig. 133. 




Funnel -breast (trichterbrust). 



Cause. Enlargement of one side means enlargement of contents. 
It may be due (1) to increase of the normal contents, as in compensa- 
tory emphysema, in which there is an increased amount of air in the 
lung, or (2) to the presence besides of abnormal contents, as fluid or 
air in the pleural sac. It is the most characteristic sign of pleural 
effusion. When the normal contents are increased the movement is 
increased ; when the pleural cavity is filled it is diminished. 

Unilateral Contraction or Diminution in Size. The costal 
angles are sharper, the plane of the anterior or posterior portion, or of 
both, is depressed, and approaches the transverse median plane of the 
chest. (See Fig. 134.) The affected side looks flat before and behind. 
The semi-circumference is lessened, as well as the diameter through 
the nipple or any fixed point. The interspaces are lessened in width 
and may be drawn in. The ribs are closer together, and may almost 
overlap. The movement of the side is lessened. 

Cause. Any diminution of contents will cause diminution of the 
affected side. This may occur from obstruction or compression of the 
bronchi of that side lessening the amount of air in that portion of the 



DISEASES OF THE LUNGS AND PLEURAE. 



485 



thorax. Theoretically, it may occur in a case in which there is com- 
plete occlusion of the main bronchus. The condition is rare, and is 
accompanied by marked associate emphysema of the other lung. The 
unilateral change is most frequently seen in cases of chronic pleurisy 
and fibroid phthisis. A large portion or even the whole of the lung 
may be bound down and compressed by thickened adhesions. The 
pleural cavity of the side thus affected, save where encroached upon 
by the heart or by invasion of an emphysematous portion of the lung 
of the corresponding side, is completely obliterated. 



Fig. 134. 




Unilateral retraction of chest, consequent upon cirrhosis of left lung, in a girl of fourteen years. 
The figures indicate antero-posterior and transverse diameters and semi-circumferences of right 
and left half of chest. (Gee.) 

Local Changes in Size and Shape. Enlargement and diminution 
are also seen. 

Local Enlargement is particularly noted in the region of the 
heart and great vessels, and will be considered when this division of 
the subject is discussed. A local enlargement in the lower anterior or 
lateral region of the chest may occur in cases of empyema, in which 
the pus tends to be evacuated, or in pulsating pleurisy. Enlargement 
in diseases of the mediastinum is usually seen in the region of the heart 
and vessels, to which reference must also be made. 

Local Contraction. This may be seen either at the apex or the 
base. At the apex the local contraction or diminution in size is seen 
above and below the clavicle. The term flattening is applied to this 
condition. The interspace is sunken and the ribs depressed. It may 
be more readily seen when looked at from behind. Flattening may 
also be either in the lateral or posterior region at the base. The an- 
terior and lateral, or the lateral and posterior, region is combined in the 
local contraction. 

Cause. The physical condition is the same as in unilateral or gen- 
eral contraction — contraction or diminution in size of the structures 
underneath. Anything which lessens the amount of air will cause 
local diminution in size, or flattening of the surface. This is notably 



486 SPECIAL DIAGNOSIS. 

seen in tuberculosis, in which affection three processes, alone or in com- 
bination, lessen the amount of air : First, occlusion of the bronchioles 
by tubercles and by inflammatory products, causing collapse of the 
alveoli ; second, the overgrowth of connective tissue which attends the 
more chronic forms of tuberculosis ; third, a localized pleurisy. Local 
pleurisy, with organization and contraction of the inflammatory exudate, 
also causes diminution of the amount of air underneath the part, or 
diminution of the contents from compression of the adjacent lung 
structure. In local contractions movement of the part is generally 
diminished. 

General Review. It must not be forgotten that the element of 
time is necessary to produce changes in shape and size of the chest, 
with the exception of unilateral enlargement. In emphysema the 
change in shape takes a long time to develop. The unilateral and local 
contractions are of slow progress, and hence, it must follow, require 
more or less chronic disease for their development. The occurrence of 
pleural effusion may cause unilateral enlargement very rapidly. 

The Movements of the Chest in Disease. Bilateral Changes. 
Frequency. The movements are increased in nearly all forms of 
dyspnoea. (See Dyspnoea.) The frequency of movement varies in many 
affections. They are more markedly increased in the acute lung affec- 
tions attended by fever, and are especially more rapid in children. 
Increased frequency of respiration does not necessarily indicate pulmo- 
nary disease. It is always seen in fever, and is a marked phenomenon 
of hysteria. Conditions outside of the chest increase the frequency, as 
enlargement of the abdomen from any cause encroaching upon the 
capacity of the chest. The respirations are lessened in frequency in 
cases of disease of the medulla in which there is pressure upon the 
respiratory centre, and in some forms of poisoning, as that due to 
opium. 

Alterations in the Rhythm of Movement. Alterations hi 
the character and rhythm of the movement are observed by inspection. 
(See Dyspnoea.) The movements may be (1) slow, and either shallow or 
deep ; (2) rapid and shallow or deep ; (3) irregular in rhythm. The 
relations of the act of inspiration to that of expiration in health are as 
5 to 6 ; in women, children, and the aged, 6 to 8. The expiration is 
longer. The expiration may be prolonged, so that it is far greater in 
length than inspiration. Length of inspiration increased. The degree 
of expansion and the duration of inspiration are increased when there 
is obstruction in the trachea or larynx. Such increased expansion of 
the upper chest is usually associated with retraction of the soft parts 
of the thorax, especially at the base. The ribs and the tissues along 
the margins of the thorax are drawn in with each inspiration. The 
space occupied by the lung above the clavicle may also be retracted. 
The transverse groove is more pronounced. If the difficulty in breath- 
ing continues, the indrawing becomes very marked, and, if the ribs 
are soft, permanent. Expiration prolonged. Inspiration is short and 
quick in cases of emphysema. The expiration is' correspondingly pro- 
longed, and the muscles of expiration are seen to be brought into full 
action. 



DISEASES OF THE LUNGS AND PLEURAE. 487 

In the consideration of dyspnoea we shall describe the appearance 
and posture of the patient and the action of the muscles of respiration. 
(See Subjective Symptoms.) 

Irregular Rhythm. By inspection the Cheyne-Stokes type of 
breathing can be noted. " Respiratory pauses " of half to three-quar- 
ters of a minute alternate with a short period of increased activity, dur- 
ing which time twenty to thirty respirations occur. The respirations 
constituting this series are shallow at first, but gradually they become 
deeper and more dyspnceic, and finally become shallow or superficial 
again. The acts of respiration are carried on by an alternation of 
pauses and periods of modified or " tidal " breathing. Sometimes con- 
sciousness is abolished during the pause. Often the pupils are con- 
tracted and inactive. When the respirations begin they dilate. 

Unilateral Changes in Movement. Increased movement of 
one side is seen when the lung of that side is acting vigorously from 
compensation, the other lung being disabled by disease. The whole 
side moves more rapidly and vigorously. The increased movement is 
associated with enlargement of the affected side and hyper-resonance 
on percussion. Unilateral diminution in movement occurs when there 
is diminution of the respiratory surface, occlusion of the bronchial 
tubes, or from causes outside of the lung. The air-space is lessened in 
cases of pneumonia, tuberculosis, or any affection which fills bronchi- 
oles and alveoli with inflammatory exudation or fluid. The air-space 
is particularly lessened by the compression of effusions in the pleura, 
of contracted and thickened exudations, and of adhesions. 

Impaired motion due to pleural effusion is almost always unilateral, 
develops gradually, following an attack of acute pleurisy, is unattended 
by pain on respiration, but is attended frequently by great embarrass- 
ment of the respiration, and sometimes by orthopnoea. Fever is usu- 
ally moderate in uncomplicated cases. It is to be recognized by the 
clinical signs mentioned and by the physical signs of fluid in the 
pleura. 

Impaired motion from chronic 'pleurisy is of long standing and 
gradual development. The chest-wall upon the affected side is re- 
tracted, and may be very markedly sunken. In the absence of accom- 
panying lung trouble there is no pain and no fever. It is to be dis- 
tinguished from other types of impaired motion by the sinking in of 
the affected side, in sharp contrast with the hypertrophy of the other 
side ; by the absence of fever and pain ; by its chronicity ; and by the 
physical signs of thickened pleura and compressed lung. Impaired 
motion from pneumothorax develops suddenly, generally in a person 
with tuberculosis of the lungs. Its appearance is usually precipitated 
by coughing, and its sudden development is marked by intense pain, 
distention of the affected side, great difficulty in breathing, and a very 
anxious expression of countenance. The escape of air into the pleural 
cavity is followed by the development of pleurisy with effusion, so that 
the affection presents the physical signs of air and fluid in the pleural 
cavity. 

The motion of the affected side is sometimes impaired in pneumonia, 
when a large portion or the whole of one lung is involved, and the air- 



488 SPECIAL DIAGNOSIS. 

vesicles are so occluded that very little air can get in. The physical 
signs in these cases resemble those of pleurisy with effusion very 
closely, but the diagnosis can be made by noting the acute onset of 
the disease, with high temperature and frequent respiration, without 
antecedent pleurisy, and by the presence of cough with expectoration 
containing the pneumococcus. 

Occlusion of the bronchus, with diminution of the movement of the 
corresponding side, is seen in rare cases in which a foreign body fills 
the lumen of the tube, or in more common cases of pressure externally 
upon the bronchus by an aneurism or mediastinal tumor. 

Impaired motion from pressure on a bronchus by an aneurism or 
enlarged lymph-gland produces the physical signs of collapse of the 
lung, coupled with those peculiar to the cause of the occlusion of the 
bronchus. It develops gradually, the patient having no pain in the 
lung. 

Outside of the lung lessened movement is caused by (1) interference 
with the muscular activity of that side from rheumatism of the inter- 
costal or respiratory muscles ; (2) pain seated either in the ribs or in 
the pleura. It may be due to acute pleurisy, the patient checking the 
motion of the affected side as much as possible, and breathing with the 
abdominal muscles, because chest respiration causes acute pain. Im- 
paired motion from this cause or from pleurodynia may be suspected 
when it has come on suddenly, and when respiration causes acute suffer- 
ing, usually depicted in the face. Pleurodynia and pleurisy are to be 
distinguished from each other by the presence in the one case of tender 
muscles, a more constant and less stabbing pain, and absence of fever, 
cough, and rales ; and, in the case of pleurisy, by the occurrence of 
stabbing pain in respiration, absence of local tenderness, and presence 
of fine, dry, or coarse rales on inspiration, with cough and fever. 

Local diminution of the movement or deficient expansion occurs 
under the same conditions that produce flattened and local contraction, 
and for the same reason. Hence deficient expansion is observed in the 
early stages of phthisis, or in local pleurisies. 

Impaired motion, due to consolidation of the lung in tuberculosis, is 
usually limited to one of the apices, and is accompanied by flatten- 
ing of the affected apex and emaciation. The condition is of gradual 
development, and presents the usual signs of tubercular consolidation 
of the lungs (q. v.). 

Sometimes the impaired motion and flattening are due to a super- 
ficial cavity from tuberculosis or abscess, and when the walls are very 
thin they may be seen to flap feebly with respiration. 

Rarer causes of impaired motion of the lung are cancer and hydatid 
cyst (q. v.). 

Fluoroscopic or X-ray Examination. Through the efforts 
of Williams, Leonard and others the X-ray has become an aid to the 
diagnosis of pulmonary affections. F. H. Williams has paid especial 
attention to thoracic diseases. I quote from some of his brilliant studies 
the results secured by such examination of the lungs : 

" In health the lungs are readily traversed by the ray ; they appear 
in the fluoroscope as light areas on either side of the backbone and 



DISEASES OF THE LUNGS AND PLEUEJE. 489 

the heart. The lower portions of the lungs, bounded by the dia- 
phragm, are seen to move up and down through a distance of about half 
an inch during quiet breathing, and to descend during full inspiration 
to a point about two and one-half inches below its level in expiration. 
The pulmonary is lighter in deep inspiration than during expiration. 
There are three principal ways in which the fluoroscope may lead us 
to suspect disease in the chest : (1) The appearance of the dark areas 
which occur in tuberculosis, pneumonia, carcinoma, diaphragmatic 
hernia, gangrene of the lungs, and in echinococcus cyst, infarction, 
pleurisy, empyema, etc., due to the increase in density, which, by ob- 
structing the passage of the ray, diminishes the normal brightness in 
the chest or changes its normal outlines ; (2) the occurrence of abnor- 
mal brightness which is found in emphysema and pneumothorax con- 
sequent upon decrease in density, which makes the lung area appear 
lighter than in health as seen in the fluoroscope ; (3) the restriction of 
the maximum excursion of the diaphragm and its altered position and 
curve from that observed in health." 

In tuberculosis the consolidated portion of the lung appears darker 
than normal in the fluoroscope. The expansion of the lung is reduced. 
The excursion of the diaphragm downward is diminished during full 
inspiration, but this muscle is carried up into the thorax as high, or it 
may be even higher than in health. From time to time the fluoro- 
scopic pictures show the apex of one lung darker, as already stated ; 
the clavicle and upper ribs less marked on the diseased than on the 
normal side ; the darker area extending more and more as the disease 
progresses. Then the apex of the other lung begins to darken and this 
area continues to extend. The diminishing excursion of the dia- 
phragm, which is also a characteristic feature of this disease, may like- 
wise be observed, and sometimes may be the earliest sign. 

In pneumonia the affected areas are easily recognized in the fluoro- 
scope, and in a central pneumonia may be seen when auscultation and 
percussion do not reveal them. The excursion of the diaphragm is 
also restricted, and the heart may be much displaced to the right, if 
the pneumonia is only on the left side. A secondary empyema, fol- 
lowing pneumonia, can be seen by the X-ray. The pleuritic effusion 
which sometimes accompanies pneumonia may be proved to exist if a 
dark area and the outline of the diaphragm below the dark pneumonic 
portion is not visible in the fluoroscope. 

In both these affections the outlines of the lower part of the chest 
are dulled or obliterated, especially the diaphragm line. If the effusion 
is large the whole chest is dark, and the heart and mediastinum are 
displaced. In a circumscribed pleurisy or empyema an exploring 
needle may fail to reach the desired spot, but we may sometimes, by 
means of the fluoroscope, exactly outline the limits of the fluid. 

Lungs that are less dense than normal, as in emphysema, give a 
brighter area than in health, and the distended lung reaches lower in 
the chest than normal. The maximum excursion of the diaphragm is 
much less than in health, as this muscle does not rise so high in expi- 
ration. These two signs are characteristic of emphysema. The en- 
larged ventricles and also the dilated right auricle are seen in late 



490 SPECIAL DIAGNOSIS. 

stages ; the heart also lies in a more vertical direction, and its position 
is not much changed by a deep inspiration. 

In pneumothorax the diaphragm is very low, loses its normal curve 
and movement on the affected side, and the heart and mediastinum 
are seen to be displaced to the healthy side. 

Palpation. By palpation the results of inspection are confirmed, 
the character and consistence of tumors ascertained, the vocal fremitus 
determined, and fluctuation detected. 

Method. The surface should be bared, although the fremitus can 
be detected through a thin layer of linen or gauze. To detect the 
fremitus in front, it is often well to stand behind the patient, with the 
palms of the hands placed over the surface of the chest in front. The 
opposite position is taken to detect the fremitus behind. The axillary 
region must also be investigated. The hands should be warmed and 
applied evenly to the surface. The two sides must constantly be com- 
pared, either by simultaneous application of the hands on the two 
sides, or by applying the hand first on one side, then on the other. 

The Vocal Fremitus. Cause. The columns of air in the bronchial 
tubes are thrown into vibration during the act of speaking. The vibra- 
tions are transmitted to the hand on the surface of the chest. They 
are known as the vocal fremitus. In infants the cry must be relied 
upon instead of the spoken voice. 

The fremitus on the right side at the apex is stronger than on the 
left, because the right bronchus is larger than the left, its angle with 
the trachea is more acute, and the bronchus going to the right upper 
lobe is two and one-half inches nearer the larynx than the left (Cary, 
Ewart). The fremitus is stronger in persons with deep, low-pitched 
voices, because the vibrations are not so rapid. It is more distinct, 
therefore, in males than in females, and in individuals with a bass 
voice. The vocal fremitus is felt more distinctly in persons with thin 
chest- walls. Thick chest- walls and large mammary glands interfere 
with the transmission of fremitus. The fremitus is not distinct in 
children because the vibrations are too rapid. 

It is well to become familiar with the vibrations produced by fixed 
monotones, in order to appreciate the fremitus. The patient is asked 
to count one, two, three, or to repeat ninety-nine three or four times. 
It is well to observe a fixed rule as to the words used, in order to have 
definitely in the mind the character of the vibrations in health, and 
the departures from the normal in disease. 

Vocal Fremitus in Disease. The vocal fremitus may be increased, 
may be diminished, or may be absent. 

Vocal Fremitus Increased. When the lung is consolidated, 
vibrations are transmitted to the hand with greater force. Fremitus 
is increased in all consolidations, as in pneumonia, tuberculosis, and 
hemorrhagic infarct. (See Fig. 135.) The fremitus may be absent 
in rare cases of pneumonia, in which the large tubes are occluded by 
exudate. The fremitus is increased in the later stages of tuberculosis, 
when cavities have formed, if the walls are dense. 

Vocal Fremitus Diminished. Anything intervening between 
the lung and the surface of the chest which interferes with the conduc- 



DISEASES OF THE LUNGS AND PLEURA. 



491 



tion of the vibrations diminishes the fremitus. The fremitus is dimin- 
ished in cases of thickened pleura, and in thin layers of pleural effu- 
sion. The fremitus is lessened if the columns of air in the bronchi 
are smaller on account of diminution in the calibre, as in bronchitis or 
in emphysema and asthma. The fremitus is lessened in cavities filled 
with fluid, or when the bronchus is occluded. 

Vocal Fremitus Absent. 1. The vocal fremitus is absent when 
the columns of air are obstructed entirely by occlusion of the bronchus, 
as by the external pressure of a tumor, aneurism, or enlarged gland. 2. 
The fremitus is absent in accumulations in the pleura of air or of fluid, 
causing interference with the vibrations. (See Fig. 136.) The well- 
known illustration of striking a stone underneath the surface of the 
water implies. If the ear of the listener is above the water, the sound 
cannot be heard. If the ear is underneath the water, the sound is 
heard a long distance from its origin. Vocal fremitus is absent in 
pneumothorax, in hydrothorax, in pyothorax, and in hemothorax. 
The same physical condition is present Avhen the pleura is greatly 
thickened, and hence the fremitus is also absent. 



Fig. 135. 



Fig. 136. 





Consolidation : Pneumonia. Vocal fremitus 
increased. (Gibson and Rdssell.) 



Pleural effusion. Vocal fremitus absent 
at a. (Gibson and Russell.) 



The vibrations produced by the passage of air through mucus or 
fluid in the bronchial tubes are transmitted to the hand when it is laid 
on the surface of the chest. It is known as the rhonchial fremitus. 
They are felt during inspiration. They may be felt all over the chest 
in bronchitis, or in asthma, as distinct vibrations, sometimes coarse, or 
again fine, indicating rapidity of movement. The vibrations may be 
transmitted over a localized area in phthisis, due to air passing through 
fluid in the cavity. They are distinct in children in cases of bron- 
chitis, and are often the source of much alarm to the parents. 

Fmction-fremitus. An exudation of lymph on the surface of the 
pleura often causes a vibration which may be transmitted to the hand. 



492 SPECIAL DIAGNOSIS. 

It is known as a friction-fremitus, and is felt in inspiration. It is 
usually felt at the base of the chest, in front, laterally, or posteriorly. 
It is not modified by coughing, and is increased by full breathing. 
The rhonchi, on the other hand, are influenced by cough and breathing. 

Fluctuation is detected by palpation in some cases of effusion, 
particularly if the intercostal spaces are swollen and tense, or if an 
empyema is about to point. In rare instances it may be detected by 
striking the chest opposite the palpating hand. 

Percussion. By percussion, (1) sounds are elicited, (2) the degree 
of resistance to the percussing-finger estimated. When a part is per- 
cussed the sounds produced are noises or tones. If a tone, the vibra- 
tions are uniform and will be in unison with a tuning-fork ; if a noise, 
the vibrations produced are without uniformity. We speak of the 
pitch, the volume, the duration, and the quality of the sound. The 
pitch depends upon the rapidity of vibrations, the number that occur 
in a definite period of time. It may, therefore, be high or low. In 
sounds that are high in pitch the vibrations are rapid. In sounds 
that are low in pitch the vibrations are correspondingly slower in the 
same period of time. The volume or intensity of the sound depends 
upon the amplitude of the vibrations, and varies directly as the square 
of the amplitude. It is modified by the degree of force used in the 
production of the sound. ' ' Duration " explains itself. These charac- 
teristics bear certain relationships. Sounds that are high in pitch are 
of diminished volume or intensity, and of short duration. The accom- 
panying diagram shows the relation of the characters of the sound. 
(See Fig. 137.) On the other hand, sounds that are low in pitch have 

Fig. 137. 



Flatness. 



Dull tone. 

Tracheal or tubular tone. 



Resonant tone. 

Tympanitic tone. 



Volume and duration. 
Diagrammatic sketch of the relations of the character of tone. The perpendicular 
line represents the pitch. The transverse line the volume and duration. 

correspondingly greater volume or intensity and longer duration. The 
three characteristics determine the quality of the sound. The term 
' • clearness " is applied to sounds which have the character of tones. 
They are low in pitch, of good volume, and long duration. Sounds 
that are high in pitch, of small volume, and short duration are of a 
dull quality. Noises, highest in pitch and least in volume and dura- 
tion, are absolutely dull or flat. The former are indicative of the pres- 
ence of air ; the latter, of the absence of air. The tones, or clear 
sounds, are naturally produced over structures containing air. The 



DISEASES OF THE LUNGS AND PLEURJE. 493 

production of a tone implies the presence of air in a sac. Structures 
in which the proportion of air to solid material varies yield sounds 
which vary between clearness and muffling, to absence of tone or dul- 
ness. Resonance and tympany are clear sounds which will be ex- 
plained later. 

Method of Procedure. Due attention should be paid to the 
presence or absence of tenderness, which necessarily modifies the results 
obtained by this method of exploration. Definite information can be 
secured by light percussion, even when there is a good deal of tender- 
ness. In children percussion should be the final step in the examina- 
tion. 

Immediate Percussion. The chest may be tapped by the finger 
or hand directly. This was the original method of percussing the 
chest. It is known as the immediate method. When the fingers are 
employed it is known as palpatory percussion. One finger is sufficient. 
The pulp, as most sensitive, may give the blow. Or the tip, the finger 
bent at a right angle, may be used. By this method the sense of resist- 
ance is better appreciated. 

Mediate Percussion. The method now employed is that in which 
a medium is placed between the chest- wall and the instrument used for 
percussing. This medium is called a pleximeter. It may be a small 
plate of ivory of suitable size to place between the ribs, or, better still, 
the fingers of the hand not used in tapping. The plessor is used to 
create the sound. It may be a small hammer. The one usually selected 
is of moderate weight, has a firm, light, slightly flexible handle and 
metal head, the poles of which are tipped with rubber. For purposes 
of class demonstration, a plessor of this character, with an ivory plex- 
imeter, is of value ; but for bedside-work the fingers of the physician 
are better. 

The Use of the Pleximeter. The pleximeter must be placed 
in close contact with the surface of the chest in performing percussion. 
If the finger is used as a pleximeter, in percussing the anterior portion 
of the chest, for instance, it must be placed parallel with the ribs. It 
must not cross them. If it is not in close contact with the chest, the 
cushions of air between the two will modify the sound, so that accurate 
data are not obtained. Interspace after interspace should be percussed 
in this manner from above downward. At the same time, if neces- 
sary, the pleximeter may be placed over the corresponding ribs, but 
parallel with them. With a little practice the method of applying the 
pleximeter can soon be acquired. 

The Use of the Plessor. This requires considerable practice On 
the part of the student. If a metal instrument is used, care should be 
taken to acquire the habit of percussing under all circumstances with 
the same degree of force. If the finger of the operator is employed as 
a plessor, several points in the procedure must be remembered. It is 
better to use one finger, preferably the middle finger. Some operators 
use more than one finger, but with a little practice a sufficient degree 
of force can be given with one to elicit the sounds essential for distinc- 
tion. The finger should be bent at right angles and kept in a fixed 
position. It must be made to strike the pleximeter perpendicularly 



494 SPECIAL DIAGNOSIS. 

to its plane. If the blow is given at any other angle to the part per- 
cussed, a true sound cannot be obtained. The blows must be regular 
and the force even. The character of the part investigated will deter- 
mine the degree of force that should be used. (See Method of Percus- 
sion, page 493.) The force of the blow is to come from the wrist alone, 
neither the arm nor the forearm must come into play. Beginning 
anteriorly with the supraclavicular fossse, and proceeding downward 
an interspace at a time, comparison should be made Avith the other side 
at each step. The axillary portions, and the posterior portions from 
supraspinous fossa? to base, should then be examined in the same way. 

Hearing and Feeling Combined. Another excellent plan is to secure 
information by the sense of touch, as well as by the sound. The 
second, third, and fourth fingers of the percussing hand are flexed at 
an angle of 45 degrees. The tips are brought down on the pleximeter 
finger and kept there for a few seconds, when the blow may be re- 
peated. The perpendicular blow is not used. The sound produced 
is not loud. It is most useful in diseases of the lungs, spleen, and 
liver, and where strong percussion cannot be used, as in perityphlitis 
and cholecystitis. 

Position of the Patient. The best position is the standing one, 
with the arms allowed to drop loosely at the sides, the head straight, 
not thrown back, and the shoulders allowed to fall a little forward if 
they are inclined to do so. Any position which throws the chest-mus- 
cles into contraction tends to defeat the object of the examiner who 
seeks to elicit the chest-sounds. In percussing the posterior portions 
of the chest it is desirable to have the patient stoop forward with arms 
folded. While this renders the muscles more tense, it has the advan- 
tage of exposing a larger portion of the chest. 

When the patient is confined to bed he should, if not too ill, be 
allowed to sit up during percussion, as contact with the bed or with 
pilloAvs deadens the sounds elicited. This fact should be borne in mind 
when from any cause it is not desirable to have the patient sit up. 

All clothing should be removed, if possible. A thin undershirt may 
be permitted from motives of delicacy, or parts only of the chest be 
exposed at one time if there be danger of chill. 

The Sounds in Health. Four types of sounds can be produced by 
percussing over the trunk for the purpose of study. 1. Resonance 
over the lungs. 2. Tympany over the caecum. 3. A modified tym- 
panitic or so-called tubular or tracheal sound over the trachea. 4. 
Dulness over the heart. Modifications of these types represent all 
sounds produced under every variety of circumstances. They will be 
considered in the order of their importance. The term resonance is 
applied to the clear sound that is produced over the lungs on percus- 
sion. It is due to the vibration of the chest- walls and of the air in 
the bronchi. ' ' Pulmonary resonance " is a term also used to indicate 
the same sound. While, as stated above, the sound produced is called 
a tone, yet on account of the relation of the air to the solid structure 
of the lung, the air being confined in innumerable sacs, a true tone is 
not produced — i. e., the sound cannot be pitched with another tone or 
made to vibrate in unison with one. For practical purposes, however, 



DISEASES OF THE LUNGS AND PLEUB^E. 495 

the term " tone " may be used convertibly with " clearness " and 
" resonance." Its characteristics cannot be defined accurately, and 
must be learned by repeated practice. 

Modifications in Health. The degree of clearness or resonance 
differs in various parts of the thorax. It is purer in the upper axil- 
lary region, at the angle of the scapula behind, and on the anterior 
surface of the chest, in the second interspace. It is slightly higher in 
pitch at the right than at the left apex. It is modified by the condi- 
tion of the chest-walls. Thick chest-walls, accumulations of fat, the 
mammary gland, and the scapulae impair the resonance and necessitate 
deep percussion to bring out the true sounds. In persons with thin 
chest-walls the resonance is clear and more pronounced. The elasticity 
of the chest-walls also modifies it. In the aged it is less clear because 
of rigid chest-walls. In children, in whom the chest-walls are elastic, 
the resonance is much fuller or clearer, and approaches more nearly the 
character of a tone. The sounds vary, within certain limits, in different 
individuals with perfectly healthy, normal chests, as may be seen from 
the above. Moreover, a sound normal in one part of the chest may 
in another part indicate disease. 

It follows that percussion-sounds do not have an absolute value ; 
their significance depends upon the individual and upon the part of the 
chest examined. The student should learn from the outset to com- 
pare the sounds developed by percussion of symmetrical portions of 
the chest, and thus determine the normal for the individual. Below 
the third rib on the left side the dulness of the heart destroys the value 
of comparative percussion. Significance : Excess of clearness or reso- 
nance — hyper-resonance — means excess of air, as in vicarious emphys- 
ema. Diminution of clearness means diminution of air — increase of 
solid structure. 

Abnormal changes in resonance caused by disease will be considered 
later. 

Tympany. When a single cavity with smooth walls, containing 
air, is percussed, the sound that is produced is a tone of low pitch, of 
considerable volume or intensity and of long duration. The term 
" tympany " is applied to this sound. In health it can be elicited 
over the stomach when it is free from food, over the large intestine, 
and at times over the small intestine. In addition to the low pitch 
and large volume, it possesses a peculiar metallic quality which is 
characteristic. It may be said to be a " hollow " sound. It is a 
quality of sound with which the student should become familiar, for 
variations are characteristic of abnormal physical conditions in the 
lung and in the abdomen. It must be remembered that tympany can 
be developed normally over the posterior portions of the lungs of in- 
fants and children. The relation of this sound to resonance, or the 
sound produced on percussing the healthy lung, and to dulness pro- 
duced over airless structures, may be appreciated by reference to the 
diagram modified from Gee. (See Fig. 137.) In pitch, in volume, and 
in duration it is lower than the resonant and tracheal tones. The latter 
stands midway between tympany and dulness. As intimated pre- 
viously, all varieties of sounds that may be produced, and which occupy 



496 SPECIAL DIAGNOSIS. 

positions between the extremes noted in the triangle, are dependent 
entirely upon the proportion of air to solid material. 

The tracheal tone is a clear tone produced over the trachea when the 
mouth is open moderately. It is clear, higher in pitch than resonance, 
and of a tympanite or tubular quality. 

Dulness. The sound over the heart is dull, and may be useful to 
compare with dull sounds yielded over areas usually resonant. If a 
dull sound has some pitch and duration, some tone is mingled with it. 
If dulness is absolute, it is without pitch and is a noise. The signifi- 
cance of dulness has been described ; it means the absence of air. Ab- 
solute dulness implies that the airless part underneath is in immediate 
contact with the surface of the chest. Relative dulness implies the in- 
terposing of air-containing structures between the airless structure and 
the chest-wall. The portion of the heart or liver in contact with the 
chest-wall yields absolute dulness when percussed ; the portion over- 
lapped by lung yields relative dulness. Absolute dulness is readily 
elicited, and with ordinary percussion is a fixed area. All observers 
will usually secure the same size of absolute cardiac dulness, for in- 
stance. Relative dulness depends so much upon the method of per- 
cussion, light or strong, and upon the ear of the observer, that for its 
extent each observer will have a different opinion. The personal 
equation is a disturbing factor in the estimation of its extent. It must 
be remembered in disease of the lungs, of the bloodvessels, and medi- 
astinum the location of the lesion is usually made out by the detection 
of relative dulness, or of changes in the pitch, quality, and duration of 
the sound, indicating less air in the part percussed. Such changes are 
more diagnostic if the effects of breathing (respiratory percussion), of 
the position of the patient, and of the force of percussion (light or 
strong) are considered. 

The Pitch. The estimation of the pitch of the sound is of the 
highest importance. It is the one distinctive attribute or characteristic 
which is of special diagnostic significance as to the physical condition 
of the part. It requires considerable practice to estimate it correctly. 

Its significance in relation to dulness and tympany has been men- 
tioned. Although a high-pitched sound may be considered a dull 
sound, this is not necessarily so. A sound of high pitch need not be 
markedly dull— indeed, it may be moderately clear. Under the right 
clavicle in health the pitch is higher than under the left, but not dull 
in character. 

The student may become familiar with the pitch, and with altera- 
tions in it, by percussing over a portion of the lung clearly resonant, 
as in the third interspace and thence downward on the right side. As 
the interspaces in apposition with the liver are reached the pitch 
changes. The fulness of the sound is lessened ; it becomes more 
shallow. The increase in rapidity of the vibrations can almost be 
appreciated, and, as they increase, the heightened pitch caused by them 
i- recognized. This normal increase in pitch is due to a thin layer of 
Lung hacked up behind by the solid liver. Change in pitch makes it 
possible to outline organs and pursue topographical percussion. 

The Degree of Resistance. This is estimated by the sense of 
touch. When organisms containing air are percussed the resistance 



DISEASES OF THE LUNGS AND PLEURjE. 497 

appreciated by the finger percussed is small, or, indeed, may be said 
to be absent entirely. The sensation of the finger is as if the parts 
underneath bounded away. When the air decreases and the propor- 
tion of solid structure increases more resistance is felt. It is of the 
greatest importance to carefully educate the finger in this sense of 
resistance. It is often difficult to determine the pitch exactly, and the 
sense of resistance furnishes an additional means of detecting the pres- 
ence or absence of solid structure. Palpatory percussion indicates 
the sense of resistance to a better degree than any other method. 

Superficial and Deep Percussion. In superficial percussion the 
blows are directed lightly over the part percussed, so as to bring out 
the sound yielded by the portion directly underneath the surface. 
Hence superficial percussion is applicable over the thinner portions of 
the lung. It enables one to bring out areas of absolute dulness. 
Light percussion is necessary in children and in patients with sore 
chest-walls, or when they have just had a hemorrhage. In deep per- 
cussion the blows are given with enough force to influence the struc- 
tures situated deeply in the lung or overlapped by the edges of the 
lung. It is necessary, therefore, in cases of deep-seated consolidation, 
and in cases of aneurism covered by lung, in order to define its limits. 
It is employed to determine the true height of the liver and the relative 
area of dulness of the heart. 

Auscultatory or Stethoscopic Percussion. This is a valuable 
means of defining the exact outline of a dull. area, as an aneurism or 
tumor within the chest, or of determining the limits of organs even 
of similar physical structure. The stethoscope is placed over the organ 
the border of which is to be defined, and percussion is begun some 
distance from it. It is conducted toward the stethoscope, and the dull 
sound of the non-resonant structure is transmitted to the ear beyond 
limits not determined by ordinary methods. If the tympany of the 
stomach is to be distinguished from the tympany of the colon, place 
the stethoscope over either one of the organs. Percuss with the finger- 
tips directly on the surface by immediate percussion. Begin at the 
stethoscope and percuss from it. As soon as the limit of the structure 
percussed is reached a difference of tone or pitch is observed which 
cannot be detected by other means. In this manner the dulness of the 
liver can be told from that of pulmonary consolidation or pleural effu- 
sion ; the dulness of an effusion from a consolidation of the lung which 
rises higher than the effusion, as in pleuropneumonia. Mediate per- 
cussion may also be employed. 

Respiratory Percussion. (Da Costa.) The difference in the sound 
elicited in full inspiration and in full expiration is marked in health. 
In general it may be said the sound becomes more resonant and higher 
in pitch in full inspiration. In ordinary bronchitis the same change 
is observed as in health ; on the other hand, in bronchitis with much 
secretion and in bronchopneumonia the marked difference between inspi- 
ration and expiration does not hold. In phthisis the difference between 
the two sides of the chest can be made more plain by respiratory per- 
cussion. By the varying changes in pitch and duration, cavities are 
detected. (Gerhardt's sign.) 

32 



498 SPECIAL DIAGNOSIS. 

Object of Percussion. The object of percussion is to estimate 
the proportion of air to the solid tissue contained in the chest. We 
can thus determine (1) the size of the lungs ; (2) the presence or 
absence of disease causing abnormal physical conditions ; (3) the size 
of the other organs in the thorax (topographical percussion), and (4) 
in the case of the abdomen the position and size of its organs and the 
presence of tumors or other solid structures. 

The Size of the Lungs. Increase in size : The boundaries of the 
lung have been described. If the resonance extends beyond these 
boundaries, it may be said that the lungs are enlarged. This is seen 
in emphysema. The area of resonance in this affection extends above 
the clavicles to a greater height than in health. It encroaches upon, 
and may altogether displace, the normal area of cardiac dulness ; it 
extends one and a half to two inches beyond the lower limits of the 
healthy lung. The upper border of liver-dnlness is, therefore, lower — 
instead of beginning in the fifth or sixth space it begins an inch or two 
below. Diminution in size : Shrinkage of the apices (one or both) 
takes place in phthisis, hence the resonance of health does not extend 
as high up in the neck. Shrinkage or contraction may take place 
along the lateral borders or lower edges, on account of phthisis or re- 
tracting pleurisy, causing diminution in size of the lung and spurious 
enlargement of the heart or liver. In diseases below the diaphragm, 
effusion or enlarged liver, the size of the lungs varies. (For heart 
and liver, see the special chapter devoted to these organs.) 

The Sounds in Disease. It may be said in general that when a 
sound is produced in the thorax which varies from the normal resonant 
tone it indicates an abnormal physical condition, or, in a word, disease. 
Exactly corresponding portions of the two sides must be compared. 

Change in tone may be general or local. The areas over both lungs 
may yield a different percussion-note from the normal (bilateral); the 
change may be limited to one side (unilateral); or it may be found in 
small areas (local). 

Increased Resonance or Tracheal Tone. The resonance may 
be increased or diminished. When the resonance is increased the sound 
is abnormally clear. If it is fuller and clearer than in health, without 
the characteristics of the tympanitic note, it is known as hyper-reso- 
nance or exaggerated resonance or a tracheal tone. The physical con- 
dition which causes exaggerated or hyper-resonance is increase in the 
amount of air. This increased amount of air may be general, unilat- 
eral, or local. When general (bilateral) it gives the characteristic sound 
heard in emphysema. In this affection the amount of air is so great, 
and the tension of the chest-walls so exaggerated, that hyper-resonance 
and sometimes a pure tympanitic sound (" band-box" resonance) are 
produced over the entire thorax. At the same time normally dull 
areas are encroached upon. The heart-dulness is effaced, the liver 
dulness lowered. The same increased resonance may be present in 
acute miliary tuberculosis. Unilateral increase in resonance or tym- 
pany occurs when there is an increased amount of air in one lung, on 
account of compensatory enlargement (vicarious or compensatory em- 
physema), or on account of an increase of air in the pleura. Local 



DISEASES OF THE LUNGS AND PLEURA. 499 

increase of resonance occurs when a local area of the lung is acting in 
a compensatory manner. This is seen in cases of phthisis in which the 
alveoli or lobules surrounding small areas of consolidation are very 
distended. The exaggerated note may aid in the recognition of a deep 
consolidated area. The same note, hyper-resonance ; or skodaic reso- 
nance, is obtained over a portion of the lung above the line of pleural 
effusion, and above the line of consolidation in pneumonia. 

Fig. 138. Fig. 139. 





Diagram showing at x moderate dulness Diagram showing heightening of pitch an- 

over tubercular infiltration. (Gibson and teriorly at x from consolidation posteriorly 
Russell.) (shaded points). (Gibson and Russell.) 

Diminished or Impaired Resonance. The normal tone or reso- 
nance is impaired or muffled — that is, the pitch is higher, while the 
volume is lessened and the duration shorter — in cases of incipient con- 
solidation of the lung, and in small pleural effusions when a thin layer 
overlaps the lung. It is the first change toward dulness. It is par- 
ticularly noted in the early stages of phthisis, when the lung area, 
usually the apex, is the seat of small areas of tuberculous infiltration. 
The relative amount of air to solid structure is lessened. Impaired 
resonance is the result. As the disease advances the note changes grad- 
ually to dulness. 

Pitch. Gibson and Russell have pointed out the change in quality 
of sound with change in pitch. (See Fig. 139.) If, for instance, the 
apex of the lung is percussed in front, when there is an effusion of fluid 
behind, or a consolidation of small area directly on the opposite surface 
of the lung, the pitch is higher, compared with the sound in the oppo- 
site lung at the corresponding point, although the quality is clear. A 
clear sound of heightened pitch is diagnostic of airless structure behind 
air-containing structure. 

Tympany in Disease. Significance : If a tympanitic note is 
elicited over a part where in health resonance should be found, it is an 
indication of disease. It signifies (1) that air is confined in a space 
(cavity), or that there is an excess of air in many sacs, as in the lungs 
in emphysema ; (2) that the tension of the lungs is less than normal — 
the lung is relaxed, as it is above the limits of a pleural effusion. A 



500 



SPECIAL DIAGNOSIS. 



Fig. 140. 



tympanitic sound from the chest occurs — 1. Bilaterally, in cases of 
emphysema. 2. Unilaterally, in cases of pneumothorax and compen- 
satory emphysema. In pneumothorax the pitch may be raised if there 
is much tension ; it is then known as a dull tympany. 3. Locally, 
a. It is limited to the lobe of the lung in some cases of compensatory 
emphysema, b. It may occur in the early stages of pneumonia, or in 
the later stages of complete consolidation. In the former it is due to 
relaxed tension ; in the latter, to the air in the bronchus, the lumen of 
which is free. c. In cases of pleural effusion, owing to alteration in 
the tension of the lung, a tympanitic note is 
present above the layer of fluid, d. In phthisi- 
cal excavations at the base of the apex, and in 
bronchial dilatation, if the cavity communicates 
with the air, and has moderately thin, elastic 
walls, and is at the same time empty, a tym- 
panitic note is produced. The musical pitch 
of the note depends upon the volume of air, 
the size of the opening, and tension of the 
wall. Large volume of air, low pitch ; large 
opening, low pitch ; greater tension, higher 
pitch. Small volume, high pitch ; small open- 
ing, high pitch ; less tension, low pitch. (For 
modifications of tympany, see Special Sounds 
and Cavities.) 

Dulness in Disease. The note is high in 
pitch, small in volume, and short in duration. 
Absence of air, or a relatively small amount 
in proportion to solid structure, is present. The 
conditions which give rise to it are all forms 
At the apex complete duiness of consolidation and pleural effusions. The 
and bronchial breathing, from ex t en t and the degree of duiness depend upon 

tuberculous consolidation; in ,-, ,. . ° . « -,. -, ■*■ . x 

the middle portion impaired tn . e proportionate amount of solid to air-con- 
resonance, from disseminated taiiiing material. Moderate duiness is seen in 
tubercles; below exaggerated tubercular disease, with moderate infiltration 

resonance, from compensatory ( . , n -. , -p^. -, n r>\ -i • -n , i 

emphysema. °* * ne lung (see Jb lg. lo8), and m small patches 

of catarrhal pneumonia, in pulmonary conges- 
tion, and in atelectasis and physical conditions in which there is solid 
material in greater proportion than in health. Absolute or complete 
duiness occurs when the air is completely absent, as in the stage of 
hepatization of acute pneumonia, in hemorrhagic infarction, in con- 
densation from pressure, in pleurisy with large effusion, or great thick- 
ness of the pleura, and in tumors. Flatness is applied to the extreme 
degree of duiness. (See Fig. 141.) 

We have, therefore, all gradations of the dull sound, from simple 
impaired resonance in incipient tuberculosis of an apex of the lung, as 
determined by careful comparison of the two apices, to absolute flatness 
or deadness. 

Method of Percussion : The kind of percussion necessary to bring 
out the duiness will depend upon the extent and the distance from the 
surface of the disease. When the consolidation or thickening is super- 




DISEASES OF THE LUNGS AND PLEURJE. 



501 



ficial, light percussion will discover it, whereas strong percussion would 
bring out the resonance of the deeper healthy lung-tissue to such an 
extent as to mask completely the superficial dulness. On the other 
hand, when the airless consolidated tissue is deep-seated and sur- 
rounded by healthy lung, strong percussion is required to discover it. 



Fig. 141. 




Exaggerated breath-sounds. Skodaic resonance 



Retracted lung. 



Air. Tympany. Metallic tinkling 
and amphoric breathing. 



Succussion on shaking. 



Loss of 



Fluid. Flat on percussion, 
vocal] resonance and fremitus. Ab- 
sent breath-sounds. 



Pneumothorax ; resonance over retracted lung. Tympany over air. Dulness or 
over fluid. (Gibson and Russell.) 



Again, when the airless tissue occupies a small focus and is sur- 
rounded by healthy lung, as in pneumonia beginning centrally ; and 
when there are small airless foci, perhaps surrounded by emphysema, 
as occurs sometimes in disseminated tuberculosis, percussion is often 
wholly negative. 

Special Sounds. Special percussion-sounds, or sounds the quality 
of which differs from the ordinary tympanitic sound, are present in 
some physical conditions. Of these the amphoric, or metallic, and the 
cracked-pot percussion-sounds are most familiar. The amphoric sound 
is tympanitic, but has a metallic clang, or echo, which is an overtone. 
The prolongation of the sound is compared to an echo. It is like the 
sonorous ring of the voice when one utters a tone in an empty hall. 
It can be imitated by percussing an empty vessel. It is heard best in 
cases of pneumothorax (see Fig. 141) and in phthisical excavation 
when the cavity is large, superficial, with smooth walls, and when it 
has open communication with a bronchus. The cracked-pot sound, as 
the name indicates, resembles that produced when a cracked metal 
vessel is tapped ; it is simulated by clasping the hands loosely at right- 
angles to each other and striking them over the knee. It is heard 
best over cavities which communicate directly with a bronchus, espe- 
cially if the chest-wall is thin and yields to the percussion-stroke. 
The cavity is usually at the apex. In order to elicit the sound the 
patient should be made to keep the mouth open. The sound should 
be created at the time of expiration, and the percussing finger should 
be retained instead of elevated after striking the pleximeter. 



502 SPECIAL DIAGNOSIS. 

In some rare cases this sound can be elicited in health. It may be 
generated if the chest of a healthy screaming infant is percussed. In 
this instance it is due to the compressed air forcibly throwing the vocal 
cords into vibration. The other pathological conditions in which the 
sound occurs rarely are pleurisy, when the chest is percussed above the 
effusion, pneumonia before consolidation has taken place, and pneumo- 
thorax if there is a free communication between the cavity and a 
bronchus. In the latter instance the sudden rush of air into the bron- 
chus produces this sound. This is proved by the fact that it can be 
created when the chest is percussed in a case of empyema, after the 
fluid has been evacuated by a free incision. It is to be noted that, 
while corroborative, it is not of itself positive evidence of any single 
condition. 

Auscultation. Sounds are produced in the act of breathing. They 
are heard by the application of the ear directly to the chest-wall or 
through some medium. They are created both in inspiration and in 
expiration: They vary in character in accordance with the situation. 

Method. If possible, the patient should sit upright in an easy, un- 
restrained position. For auscultation in front, the arms should hang 
carelessly by the side. For auscultation behind, the patient should fold 
the arms and lean slightly forward. For comparison both sides should 
have the same freedom of movement, which would not be attained if 
the patient assumed a lateral or side posture or attitude. Auscultation 
should be practised in quiet, in full and in forced inspiration and ex- 
piration. 

Auscultation is practised by two methods : First, the ear is applied 
directly to the chest, a thin towel or napkin free from starch alone 
intervening. This is known as the immediate or direct method. It is 
of service to ascertain the general character of the sounds. It has the 
disadvantage of imperfect localization. Second, by means of the stetho- 
scope and phonendoscope the mediate or indirect method is practised ; 
but it is disadvantageous in infants, because they cannot be kept quiet 
or are sensitive to its pressure, and in children because instruments 
are alarming. 

The advantages of the stethoscope over direct methods of ausculta- 
tion are seen when it is necessary to localize sounds. The definite 
localized area in which the sound is produced can be ascertained, and 
sounds in close proximity differentiated. Its use is essential in the 
study of heart-sounds. In addition, the operator is more likely to 
escape from contagious diseases and vermin. Moreover, on the score 
of delicacy, the stethoscope is preferable. 

The stethoscopes used are single and double, and vary in form with 
the practice of the operator. It should be an absolute rule with 
the student to become familiar with and use one form of stethoscope 
only. The single stethoscope is very good to localize and determine 
the relation of sounds. It also transmits the shock of an aneurismal 
vessel or of the heart. The objection to it is that the weight of the 
head causes pain if the chest is sore, and the pressure of the instrument 
may modify sounds if bloodvessels are auscultated, or sounds in close 
proximity to the ear, as a friction. In the use of the single stetho- 



DISEASES OF THE LUNGS AND PLEURAE. 503 

scope the student should be particular, first, to see that the portion 
applied to the chest is perpendicular to the plane of the area over which 
auscultation is practised. Otherwise slight tilting of the instrument 
will take place and outside noises be transmitted through the tube. 
The operator should place himself in an unconstrained position and 
see that his head is accommodated to the position of the instrument, 
not the latter to the head. If the parts over which auscultation is 
practised are covered with hair, an extraneous sound from friction is 
produced. Oil should be applied to obviate this. The double stetho- 
scope is the most suitable for class instruction. It can even be applied 
over parts that are quite tender. The rule of application to the chest 
is the same as for the single stethoscope. The ear-pieces should fit 
comfortably. The humming sound in the tube is confusing at first. 

The Sounds in Health. It may be well to call attention to the 
confusion that always arises when the student is examining the chest 
for the first time. The probability is that the coincidence of heart- 
sounds and lung-sounds in the chest prevents the discrimination of 
the latter sounds. If attention is paid to the respiratory rhythm 
they can be distinctly isolated. When the student is ausculting the 
lungs he should place his hand on the thorax or the epigastrium and 
fix his attention upon the two acts of respiration — inspiration and ex- 
piration. Note the occurrence of each movement, the expansion of 
inspiration and the contraction of expiration Then analyze carefully 
the sounds during each event of a respiratory act. Having fixed the 
attention on respiration, noted its divisions, and excluded cardiac 
rhythm, note (1) the character of the sound in inspiration ; (2) the 
character of the sound in expiration ; (3) the relative length of the two. 
By this means the sounds of respiration are accurately ascertained, and 
confusing extraneous sounds, as from the heart, distinctly eliminated. 

Bronchial Breathing. If the stethoscope is placed over the 
trachea at the top of the sternum, a sound characterized as follows 
will be heard : First, it attends inspiration and expiration with a defi- 
nite pause between ; second, the inspiration and expiration are nearly 
equal in length ; third, they are of a tubular, blowing character. The 
expiration is perhaps a little stronger and longer than the inspiration. 
If the mouth is closed, there is no change except that both inspiration 
and expiration are harsher and sharper. Bronchial breathing is the 
term applied to the sound which is heard in this situation. It is one 
of the • normal sounds of the chest. It may be heard behind, at or a 
little below the seventh cervical vertebra, feebler in quality than in 
the trachea, and in the interscapular space over the large bronchi as 
they leave the trachea. A sound heard in these areas, bronchial in 
character, is normal. 

Vesicular Breathing, or the Respiratory Murmur. If the 
ear is applied over the anterior portion of the chest, or, better still, in 
the upper axilla or below the angle of the scapula behind, a sound is 
heard both on inspiration and expiration. It differs from bronchial 
breathing, however, in that inspiration and expiration are changed in 
length. The sound of inspiration is twice or three times as long as 
the sound of expiration. The sound of inspiration is soft, breezy, or 



504 SPECIAL DIAGNOSIS. 

sighing in character, increasing in intensity to the end of full inspira- 
tion. It is immediately followed by expiration, which diminishes in 
intensity as the air is expelled, and terminates when one-half or two- 
thirds of the expiratory act is completed. The sounds can be imitated 
bv breathing with the lips in the position required to pronounce " f " 
or " v." 

Cause of the Sounds. The sound is caused by the passage of air 
through the nares into the wider pharynx when the mouth is closed. 
The sounds heard over the bronchi, the terminal bronchioles, and the 
vesicles are probably created in the upper air-passages and transmitted 
to the ear through the medium of the bronchi. Bronchial breathing 
is the sound unmodified, transmitted to the ear, weakened only by its 
distance from the upper air-passages. The vesicular breath-sound is 
the same sound modified on account of the intervention of the air- 
vesicles between the ear and the larger bronchi. The sound is thus 
smothered or dampened down. It was held that part of the sound of 
vesicular breathing, if not the whole, was due to expansion of the vesi- 
cles and rush of air through the bronchioles. The proof, however, 
seems to be in favor of the first view given, chiefly because, when the 
vesicular tissue is removed, as in pneumonia or other consolidation, 
even far distant from the trachea, bronchial breathing is produced. 

Modifications of the Sounds in Health. Exaggerated Breath- 
sounds. Bronchial breathing and vesicular breathing are increased in 
loudness and sharpness by strong, rapid breathing. In some persons 
a sound is heard which partakes of the qualities of both bronchial 
breathing and the vesicular sound. It is noticed in the interscapular 
region about the level of the spines of the scapulae, replacing the pure 
bronchial breathing which is heard in other individuals. Its characters 
are, first, soft, blowing inspiration, or loud, harsh inspiration ; second, 
slightly prolonged blowing expiration, more exaggerated, louder, but 
not harsher, than in health. The term broncho-vesicular is applied to 
this kind of breathing. It is due to the fact that the sound produced 
in the upper air-passages is conducted to the ear less dampened down 
or modified, because the air-vesicles which surround the bronchus are 
here smaller in number than are found in the remainder of the lung. 

The sounds are increased in children, in whom there are combined 
greater elasticity of the chest-wall and greater friction throughout the 
smaller bronchi, which are relatively larger. So distinct and charac- 
teristic is the sound in children that the term puerile respiration is 
applied to it. The sounds of inspiration and expiration are both in- 
tensified or sharper than in healthy adults ; the latter is relatively pro- 
longed. 

Feeble Breath-sounds. The sounds are modified by the condition 
of the chest-walls. If they are thick, or there is an abundance of fat, 
the sounds are fainter or lessened in intensity. Feeble respiratory 
power, in wasting and exhausting diseases, causes feeble breath-sounds. 
The condition of the upper air-passages, even if not pathological, mod- 
ifies the sound. If the glottis is small, or there is a disturbed relation- 
ship between the nose and pharynx, the sounds will be modified. 
They are usually weakened. 



DISEASES OF THE LUNGS AND PLEURJE. 505 

The Sounds in Disease. It is well for the student to bear in mind 
that sounds heard in the chest which are departures from the normal 
sounds always indicate disease. 

Vesicular Breathing Exaggerated. Bilateral, The vesicu- 
lar breathing or respiratory murmur is increased, first, when there 
is increase in the force of breathing — when normal respiration is in- 
creased and the patient takes full, deep breaths. It is seen in some 
forms of dyspnoea, as at the acme of Cheyne-Stokes breathing, or in 
the dyspnoea of diabetic coma. It may be increased or exaggerated 
in certain forms of bronchitis, particularly when the small tubes are 
narrowed by inflammatory swelling. 

Unilateral exaggeration or increase of vesicular breathing is heard 
when the lung is acting vigorously or in a compensatory manner. The 
strong inspiration followed by strong and relatively prolonged expira- 
tion of an actively moving lung signifies almost certainly disease of the 
lung of the opposite side. 

Local exaggeration of vesicular breathing, the inspiration harsh, is 
noted in cases of phthisis in its earliest stages. It should be compared 
with the sound of the opposite side, when the difference can easily be 
ascertained. It is heard over the apex, in pneumonia or pleurisy of 
the base, and vice versa. 

Vesicular Breathing, Diminished or Absent. Bilateral. (1) 
It is lessened in all cases in which the expansion is interfered with. In 
feeble persons the respiratory murmur is weak, particularly at the 
bases posteriorly. If the muscles of respiration are paralyzed or en- 
feebled, the murmur is also lessened. If the expansion is interfered 
with, on account of disease of the diaphragm, or pressure upward by 
accumulations in the abdomen, it is weakened. 

(2) Anything which lessens the amount of air supplied to the chest 
diminishes the vesicular breathing. It is, therefore, lessened in cases 
of occlusion or obstruction of the nares, the pharynx, or the larynx. 

(3) Thickened chest- walls that occur from disease, as oedema, weaken 
the respiratory sound. 

(4) The vesicular breathing is weakened throughout the entire extent 
of the lung in emphysema. The enfeebled respiratory forces and the 
short act of inspiration in this affection cause less air to enter the already 
overfilled chest. Moreover, in the bronchitis that attends emphysema 
the bronchioles are all more or less occluded, and hence the air-supply 
is diminished. These conditions lead to feeble respiratory murmur 
except at the anterior margins of the lungs. 

Unilateral diminution of breath-sounds occurs (1) when there is nar- 
rowing of the bronchus, as in cases of aneurism or mediastinal tumor ; 
(2) when there is pleural effusion, which (a) lessens the amount of air- 
pressure by compression of the lung and (6) interferes as a different 
conducting medium. (See Fig. 136.) If pain in pleurisy, pleurodynia, 
or neuralgia is present on one side, the breath-sounds of the affected 
side will be lessened. Not only in pleural effusions from serum, blood, 
pus, or air, but also in thickened pleura there is weakness or faintness 
of the respiratory murmur. It should not be forgotten that effusions 
and thickenings of the pleura rarely take place bilaterally ; when they 



506 SPECIAL DIAGNOSIS. 

do occur the breath-sounds are weakened, but not to the same extent 
as when an effusion is limited to one side. 

Local diminution of breath-sounds occurs in the early stages of phthisis 
or in the earliest stages of pneumonia. 

Alteration of the Rhythm. We take cognizance of the rhythm 
of the sounds. In health the movement of inspiration and that of 
expiration are almost equal, but, as previously noted, the sound of in- 
spiration is heard during the entire act, while that of expiration occu- 
pies the first third or so of the act. The sound produced during 
expiration may even be less than half the length of that produced 
during inspiration. The following proportion represents relative 
lengths — Ins. : Exp. : : 3 : 1. 

Expiration Prolonged. The first notable change in the rhythm 
of respiration may be prolongation of expiration. When the expira- 
tion is prolonged it equals inspiration, or may even be longer. This 
is due to the difficulty of getting the air out of the chest — expiratory 
dyspnoea, a physical condition which enables the sound of expiration 
to reach the ear. Hence, prolongation of expiration all over the chest 
is seen in emphysema and asthma. In this condition the inspiration 
is short, the expiration prolonged. Although distinct throughout the 
chest, it is more pronounced above the clavicles and along the free 
margins of the lung anteriorly. It is prolonged in bilateral broncho- 
vesicular breathing (q. v.). 

Local prolongation of the expiration is of great diagnostic significance. 
It occurs when areas of the lung are partially consolidated and the 
elasticity thereby impaired. The respiratory murmur is harsh, or 
puerile, or it may be weak. This condition obtains in tuberculosis, 
and is one of the first physical signs of this affection. 

Jerking or Interrupted Inspiration. Instead of the smooth, 
even, sighing, or breezy inspiration the sound is created in puffs or 
jerks, so that during the act of inspiration, as the chest expands, a 
number of successive vesicular sounds are heard until the act is com- 
pleted. The physical condition which causes jerking inspiration, or 
cog-wheel breathing, is found in the earlier stages of tuberculosis, 
when the various bronchioles are more or less occluded by outgrowths 
of tubercle. The air, therefore, enters different lobules at different 
periods of time, thereby giving rise to this peculiar broken sound. It 
must not be confounded with the same character of breathing that is 
heard adjacent to the heart, due to the pressure of that organ, or of 
structures in intimate relation therewith, upon portions of the lung, on 
account of which air enters various areas in puffs. On the other hand, 
jerking inspiration sometimes occurs in health. It is simulated by the 
jerky act of inspiration in nervous patients. It is of no significance 
unless attended by other physical signs. 

In cases of adhesion at the apex, particularly of the left lung, the 
same puffing or jerking inspiration is often heard. It is also present 
in aneurism, or disease of the aorta, pressing upon a bronchus, causing 
the air to enter the part in an intermittent manner. When pathologi- 
cal jerking breathing is present, the expiration is prolonged, and, if the 
case is under observation a sufficiently long time, bronchial breathing 



DISEASES OF THE LUNGS AND PLEUBJE. 



507 



will usually replace the jerky respiratory murmur in progressive con- 
solidations. Small, moist rales, excited by coughing or a full breath, 
usually attend jerking breathing when it is pathological. 

Bronchial Breathing. The normal situation of bronchial breath- 
ing in health has been indicated. If the same kind of breathing is 
heard in any other portion of the lung it is pathological. It is gener- 
ally indicative of the presence of consolidation. The spongy lung- 
tissue is replaced by solid conducting material, by which the bronchial 
sound is conducted to the ear. It is heard, therefore, in all pathologi- 
cal conditions in which consolidation takes place. It is the typical 
form of breathing heard in pneumonia, in consolidation of the lung due 
to tuberculosis (see Fig. 142), in hemorrhagic infarcts, and in lung 
syphilis. It must not be forgotten, however, that cases of pneumonia 
do exist without this type of breathing. This is the case when the 
large bronchus supplying the lungs, or the bronchioles, are occluded by 
inflammatory exudate. In tuberculous consolidation it may be absent 
for similar reasons. In central pneumonia, where consolidation is deep- 
seated and surrounded by lung-tissue, bronchial breathing may not be 
heard, or it may be postponed until the third or fourth day of the disease, 
by which time consolidation will have reached the surface of the lung. 



Fig. 142. 



Consolidated area. 

Fremitus increased. 
Vocal resonance increased. 

Dulness on percussion. 



Bronchial breathing. 




Increased vocal resonance 
and fremitus. Dnlness. 

Cavity with cavernous 
breathing and gurgling 
rales. Pectoriloquy. 

Hyper-resonance on per- 
cussion. 

Consolidation — bronchial 
breathing. Increased 
fremitus and resonance. 
Dulness on percussion. 



Tubercular infiltration. 
Impaired resonance on 
percussion. 

Congestion— crepitant and 
subcrepitant rales. 



Showing phthisis at various stages. (Gibson and Russell.) 



In certain cases of pleurisy with effusion bronchial breathing exists. 
The accumulation is not great enough to compress the lung completely. 
The bronchial tubes remain patent, while the vesicular structure is 
compressed. Low-pitched bronchial breathing is heard under these 
circumstances. It is more pronounced at the upper layer of the effu- 
sion. It is. always heard close to the spine posteriorly, where the lung 
is compressed. Sometimes it is heard above the limit of the effusion, 
in all probability because of relaxed tension of the lung. 

Varieties of Bronchial Breathing. Its special characteristics 
must be borne in mind. (See p. 503.) It must not be forgotten that 



508 SPECIAL DIAGNOSIS. 

bronchial breathing is not represented accurately in every instance by 
the sounds heard over the trachea. Its character may be modified and 
yet approach that type of breathing. The modification occurs in one 
or both of the two portions that go to make up the sound : (1) The 
blowing element may not be as distinct in inspiration as in expiration ; 
(2) in rare cases, the characteristic blowing sound may not continue so 
long during expiration as to equal the inspiratory sound. On the other 
hand, (3) the bronchial breathing may vary in pitch. At times it is 
(a) high in pitch, both in inspiration and expiration, but with a pure 
blowing quality (harsh) attending each. It may be (6) soft and low in 
pitch attending both acts. The strong, high-pitched sound emitted 
by breathing deeply when the lips and tongue are placed in position 
to pronounce " ch " is termed tubular breathing. It is the characteristic 
sound of croupous pneumonia. (4) The loudness of the sound may 
also vary. This depends largely upon physical peculiarities of the 
individual. The condition of the chest-walls and the force of breathing 
determine it. 

When pleurisy with effusion coexists with pneumonia, the bronchial 
brea thing, which should be audible, is feeble and distant. Under the 
same circumstances a bleating sound replaces bronchophony. (See 
-Egophony.) 

Mode of Determination. Breathing which may, during very 
quiet respiration, appear to be normal, is sometimes discovered to 
be bronchial when the patient has a spell of coughing and then takes 
several deeper breaths than usual in rather quick succession. Some- 
times the noise made in nasal respiration obscures the pulmonary 
sounds. The patient should be instructed to breathe with the mouth 
open, to take somewhat deeper breaths than usual, and to let expiration 
follow at once upon the close of inspiration. Many patients when told 
to take deep breaths expand their lungs to the utmost, and then hold 
the air in a while, and allow it to pass out slowly. Such a method 
usually defeats the purpose of the examiner, which is first to note the 
relative length of inspiration and expiration, and then the quality of 
the two sounds, first, as compared with each other, and, secondly, as 
compared with the normal. In listening for bronchial breathing the 
attention should be fixed more upon the length and quality of the expi- 
ratory sound, and it is, therefore, important that the patient breathe so 
as to bring out its characteristics more clearly ; this he can do by 
taking several moderately deep breaths in quick succession and with 
the mouth open. 

Modifications of Bronchial Breathing. If a case of tubercu- 
Lous consolidation is watched, it will be found after a time that the 
bronchial breathing becomes lower in pitch. It is heard in inspiration 
and expiration, but a more hollow quality attends the sound. From 
the hollowness of the tone the word cavernous has been applied to the 
breath-sound ; it is due to the formation of a cavity in the consolida- 
tion, or to a dilated bronchus. It is a sign of a cavity. (See Fig. 142.) 
Cavernous breathing may have a metallic quality, and is then called 
>> m j >// oric. It is analogous to the sound produced by blowing across 
the open mouth of a jar. A large cavity with smooth walls that com- 



DISEASES OF THE LUNGS AND PLEUBJE. 509 

municates with the air is the cause of the development of such sound. 
It is heard also in pneumothorax, when such communication exists. 
The metallic tone is analogous to the metallic percussion-sound. It 
occurs under the same physical circumstances. The physical condition 
which causes it may be so marked that the same character of tone is 
imparted to rales produced in the cavity, or to the heart-sounds which 
are transmitted by the solidified area surrounding the excavation. 

Bronchovesicular Breathing in Disease. The physical con- 
dition is more or less consolidation surrounded by vesicular structure, 
as in the early stages of tuberculosis. It is found midway in the 
change from respiratory murmur to bronchial breathing in progressive 
consolidations. The inspiration is higher in pitch ; the expiration 
prolonged, harsh, and blowing ; or the former may be bronchial or 
tubular, the latter absent. It may, however, be indistinct or masked 
by rales. It is sometimes heard in the earlier stages of pneumonia, 
and is the modified bronchial breathing heard over small consolidated 
areas in capillary bronchitis and catarrhal pneumonia, with collapse of 
lobules. The term " transition breathing" has been applied to this 
character of breath-sounds. 

New Sounds. The foregoing sounds are modifications of the nor- 
mal sounds heard during the act of breathing. New sounds or adven- 
titious sounds are created in the lungs or in the pleura. In the lungs 
the term rales is applied to them, and in the pleura they are known as 
friction-sounds. Under the same head may be classified the succussion- 
sound and metallic tinkling. 

Bales. Bales are sounds created in the bronchi, bronchioles, and 
air-vesicles, or in pathological excavations (cavities). They are due 
(1) to the passage of air through bronchial tubes which are narrowed, 
either on account of swelling of the mucous membrane or on account of 
spasm ; or (2) the passage of air through fluid (mucus, serum, pus, 
blood). The former are called " dry rales ;" the latter moist rales, or 
crepitation. When the dry rales are continuous — i. e., heard during 
both the acts of inspiration and expiration — they are known as rhonchi. 
Dry rales are musical ; moist rales are not. When heard over con- 
solidated areas, the latter are, however, usually accompanied by over- 
tones (resonance transmitted from the bronchi), and are then clear and 
sharp — " consonirende Basselgerausche," Skoda. 

Dry Bales are divided into («) sonorous and (b) sibilant. The 
former are large rales, the character of which is indicated by the name. 
They are created in the large bronchial tubes. They are coarse, low- 
pitched musical sounds. Sibilant rales are created in small tubes, and 
are high-pitched, whistling sounds. Both are heard only over the 
areas of their creation, although the sonorous rale may be transmitted 
all over the chest. They may be heard at the same time. The dry 
rales are heard in the early stages of bronchitis, when the mucous 
membrane is swollen and thickened, but has not begun to secrete 
mucus or mucopurulent matter. They are also heard in asthma 
in which there is spasm of the bronchial tubes, and in the chronic 
bronchitis of emphysema. In the latter the smaller rales are more 
common. 



510 SPECIAL DIAGNOSIS. 

Moist Rales, or Crepitation. They may be divided into large 
or small rales ; the latter are also called subcrepitant. (See Fig. 142.) 
The crepitant rale is a fine rale, said to be created in the alveoli, due 
to inflation of the cells, the walls of which have been held together by 
exudation or fluid (oedema). It is a fine rale distinctly localized, resem- 
bling the sound produced by rubbing a lock of hair between the fingers 
or by putting salt on a hot plate. In the early stages of pneumonia 
and in oedema of the lungs it is said to be pathognomonic. It may, 
however, be heard whenever there is a small amount of fluid in the 
alveoli and feeble respiratory action. The small, moist or subcrepitant 
rales are created in the smaller bronchioles and the alveoli. They may 
be general or local. If general, they are due to bronchitis in the 
second stage. There is an abundance of secretion in the terminal air- 
passages which is thrown into vibration by the current of air during 
the act of breathing. The element of moisture is pronounced and 
gives to them their quality, to which the term " crackling " is some- 
times applied. They are found in congestion with outpouring and 
stagnation of secretion ; in oedema ; and whenever fluid is drawn into 
the bronchi, as when there has been a hemorrhage in the upper pas- 
sages. Small moist rales in local areas are found in phthisis, partic- 
ularly at the end of the first stage, on account of the local bronchial 
catarrh, and in the second stage for the same reason. They occur in 
the early stage of pneumonia, particularly in the area of the lung which 
is the seat of collateral oedema adjacent to the consolidation. They 
are also heard in the later stages of pneumonia when resolution has 
taken place. If this is reached, however, they may be replaced by 
large rales. They may be heard around any consolidation because of 
congestion, oedema, or catarrh. It must not be forgotten that cough 
or forced inspiration must be excited before rales can be definitely ex- 
cluded. 

Large moist rales, or mucous rales, occur in the larger bronchial tubes, 
or in cavities, from the same causes that produce small rales. The 
fluid, however, is larger in amount, the air-current stronger, and the 
space for vibration is greater. While sometimes present in bronchitis, 
they are heard in their most marked form in the third stage of phthisis. 
They are described as bubbling and gurgling rales, and are very char- 
acteristic after a full breath or a cough. (See Fig. 142.) 

Rales are to be distinguished from other adventitious sounds. 
Although in some instances, as when rales are heard over the bases of 
the lungs, it is almost impossible to distinguish them from friction 
sounds, they have nevertheless certain marked characteristics. We 
recognize rales, first, by the qualities previously mentioned. Second, 
by their location; if the adventitious sounds are general, they are due 
to rales. Third, rales are modified by cough or breathing. They may 
bo intensified by either act, or, after the completion of the act, may 
disappear entirely. On quiet breathing, in the early stages of tuber- 
culosis, for instance, they may not be heard at all. It is absolutely 
necessary, before excluding them, to have the patient cough and then 
t;i l<<: a full breath. Fourth, they vary in position. This may occur from 
hour to hour. If the chest is examined in the morning, they may 



DISEASES OF THE LUNGS AND PLEUBJE. 51 1 

be more pronounced, for instance, at the base. At another time in the 
twenty-four hours they are distinct at the apex. They are more likely 
to be present at the base if the patient is kept in the recumbent posture. 
Fifth, they vary in character. At one time small, moist rales are 
heard ; in a short time they are replaced by larger rales. Dry rales 
are regularly followed by moist rales in the course of bronchitis. In 
a case of bronchial asthma all sorts of rales may be heard in a few 
hours. Sixth, they are distant. They seem to be further away from 
the listening ear than are friction-sounds. 

Rales in the bronchi must not be confounded with the crepitant or 
fine crackling sound which is heard at the base of the lung in patients 
who have been ill with the exhaustive fevers and who have not taken 
full breaths for some time. They disappear after the patient has in- 
spired deeply half a dozen times. 

Rales throughout the lung are not, in themselves, diagnostic of any 
affection save bronchitis, in which, with the absence of other physical 
signs, their occurrence all over the chest is significant. In the absence 
of this affection rales at the base of both lungs are due to congestion. 
Rales at one apex, with failing health, point to the onset of tubercu- 
losis. 

Friction-sound. In health the two surfaces of the pleura rub 
together without making any sound. If they are inflamed, the sur- 
faces are roughened, as swelling and dilatation of the capillaries pro- 
duce a more or less granular surface, or because of transudation of fluid 
or lymph. Under these circumstances rubbing together of the two 
surfaces creates a sound, to which the term friction is applied. It is 
heard at the end of inspiration, and may continue during expiration. 
It is a localized sound, usually at the seat of pain ; it is near the ear, 
and is not modified by cough or full breathing, except occasionally 
by the latter when repeated. It occurs in " nests " or " bunches." 
It may be increased by the pressure of the stethoscope. Moreover, it 
is a fixed sound, in that it does not disappear until effusion takes place. 
It may reappear again when the fluid subsides. The above character- 
istics distinguish it from rales. Both, however, may occur together. 
Although almost always of respiratory rhythm, when the pleurisy is 
in the neighborhood of the heart, the friction may be of cardiac 
rhythm. Under these circumstances it is more distinct during the act 
of inspiration. It is heard as a systolic rubbing, often of respiratory 
rhythm, along the borders of the heart. 

We not only distinguish the friction-sound by the characters just 
indicated, but also by the presence of pain, which renders its existence 
more probable. Usually it is heard at the base, in the nipple-line in 
front, or at the angle of the scapula behind, and frequently in the 
axillary region. 

In addition to the friction-sound of acute pleurisy, dry creaking 
sounds, not unlike the sounds produced when an old door is swung on 
rusty hinges, or when new leather is bent, are heard in cases of old 
pleurisy. Other physical signs of pleural adhesions are present, and a 
friction-fremitus is often transmitted to the hand. An old or dry fric- 
tion is often heard at the apex, in the neighborhood of old cavities. It 



512 SPECIAL DIAGNOSIS. 

attends both inspiration and expiration, is not modified by cough, nor 
has it any of the elements of the moisture that attends moist rales. 
The patient may be cognizant of the grating or rubbing sensation, and 
be able to describe the sensation during each breath. It may continue 
a long time after an acute pleural effusion has disappeared, and is 
sometimes the source of anxiety upon the part of the patient. 

Pvasmic deposits in the lungs, infarction, bronchiectasis with reactive 
pneumonia, and pleurisy with emphysema, are first revealed by pleu- 
ritic frictions (Vierordt). At the base of the right lung they may 
be the first indication, or at least an early one, of hepatic abscess 
(Clark). The pleural friction in the hepatic region must not be con- 
founded with peritoneal friction of respiratory rhythm. In a case 
of secondary cancer of the liver a friction-sound was heard in the 
seventh interspace from perihepatitis over a cancerous nodule. 

Metallic Tickling. The impression imparted to the listener is 
that of the falling of some material into fluid in a hollow space. The 
physical condition is that of a cavity partly filled with fluid, partly 
filled with air, into which there is dropping from an opening above. 
It is seen in hydropneumothorax or pyopneumothorax and in a few 
cases of large cavities. The air-chamber acts as a consonance-box and 
resonator, and gives a metallic quality to the sound. Other physical 
signs of cavity and fluid are associated. It may be heard when the 
patient is breathing quietly, or only after coughing. Sometimes only 
tinkling is heard, or the sound of a number of drops is transmitted. 
The latter occurs after coughing. 

Bell-tympany. The bell-sound is heard when air is confined in 
the pleura. If the stethoscope is placed over the pleural cavity, and 
two coins are used as plessor and pleximeter, a distinct metallic or 
anvil-sound is transmitted to the ear. The cavity containing air can 
be clearly outlined if the metal pleximeter is moved about. As soon 
as it passes over a part of the chest under which no air is confined the 
sound is not heard. Although heard in nearly all cases of pneumo- 
thorax, there are some cases in Avhich it cannot be elicited, probably 
because of the small size of the aperture in the pleura. 

Succussion. The ear is placed to the side of the chest, and the 
patient's body moved suddenly by himself or by the observer. A 
-plashing sound is heard. It can only be produced when there is air 
as well as fluid present in a cavity. It was first described by Hippo- 
crates, and the term " Hippocratic succussion " has been given to it. 
It is characteristic of hydropneumothorax, although not present in all 
cases of this disease. The sound may be audible at a distance. Metal- 
lic tinkling can usually be heard at the same time. 

Auscultation of the Voice. When the ear or stethoscope is applied 
to the surface of the chest and the patient is asked to speak, the vibra- 
tion- of the air in the trachea and bronchial tubes are transmitted to 
ili«' chest-wall and become audible. The sound is known as the vocal 
resonance, it is a si<^n which goes hand-in-hand with vocal or tactile 
fremitus and is modified by the same conditions which modify the 
latter. While, in general, conditions which increase the fremitus 
increase the vocal resonance also, this is not invariably the case. 



DISEASES OF THE LUNGS AND PLEURAE. 513 

Sometimes one is increased and not the other, without there being any 
evident reason for it. 

Vocal Resonance in Health. It varies in health conjointly with 
the fremitus. The sound is purring or buzzing. It is heard more 
pronouncedly at the right apex than at the left ; in persons with thin 
chest- walls ; in individuals in whom the voice is low in pitch and 
strong. It is lessened, therefore, in females and children. It dimin- 
ishes the further away the ear gets from the larynx, and hence is 
feebler at the bases. It is immaterial what words are selected by the 
patient to create the resonance. It is important for the student, how- 
ever, to become familiar with the resonance of a definite series of words 
which when pronounced do not need any marked change in inflection 
of the voice. The words " one/' " two," " three," or " ninety-nine," 
spoken repeatedly, are selected. The patient should not raise or lower 
his voice during the act of speaking. Symmetrical portions of the two 
sides of the chest must be examined successively. 

Vocal Resonance Increased. Increased vocal resonance de- 
pends upon the intensity or extent of the cause. When slightly above 
normal it is referred to as slight increase, or when the voice is trans- 
mitted comparatively distinctly to the ear it is known as bronchophony. 
This may be heard in health over the trachea, or over the bronchi be- 
hind. When heard over the vesicular structures of the lung, it indi- 
cates that the vibrations are transmitted to the ear by some better 
conducting material. This is usually a consolidated lung, and hence : 
1. In all cases of consolidation the resonance is increased, that is, bron- 
chophony is created ; but in pneumonia, if the bronchus is occluded by 
exudate, it is absent. 2. If the lung is collapsed but the bronchi open, 
the resonance is increased. 3. It is also increased in cavities. Some- 
times the resonance is intensified and the sound is even more pro- 
nounced than when heard over the trachea. 

Pectoriloquy. The voice may be so distinctly transmitted that 
we have the impression that the patient is speaking into the mouth of 
the stethoscope. If the patient speaks slowly the words may be dis- 
tinctly heard. It is more striking when the patient whispers. The 
term " whispering pectoriloquy " is then applied to it. It is detected 
over a cavity if it communicates with a large bronchus, and sometimes 
in consolidation of the lung. 

Vocal Resonance Diminished. Vocal resonance is diminished 
or absent when anything cuts off the supply of air, and intercepts the 
vibrations from the part over which the observer is auscultating. Frem- 
itus and resonance are absent over the area supplied by a bronchus 
which is occluded by external pressure, as an aneurism. Diminution 
or absence of vocal resonance is more marked in cases of pleural effu- 
sion (serum, blood, pus, or air) or thickened pleura. The vibrations 
are impeded because of the difference of conducting material. The 
degree of diminution depends upon the amount of effusion. 

Modifications of Vocal Resonance. 1. At the uppermost 
limit of the pleural effusions, at which point the layer of fluid is thin, 
the resonance is transmitted in a modified form. It is tremulous and 
bleating in character, and is known as cegophony because it resembles 

33 



514 SPECIAL DIAGNOSIS. 

the bleat of a goat. It is especially heard at the angle of the scapula, 
or below it in cases of moderate effusion. It is due to the fact that 
the fundamental tones are intercepted by the fluid, while the other 
tones are allowed to pass through and give the peculiar bleating sound 
(Gee). 2. The vocal resonance may have a metallic character in pneu- 
mothorax when there is free communication with the bronchus. 

Cavities. Pulmonary cavities are due to destruction of lung by 
abscess, gangrene, or tuberculosis, or to dilatation of the bronchi. 

As there is usually a local increase in the amount of air in cavities, 
there is in consequence a local area of exaggerated resonance, or tym- 
pany, and with it the occurrence of cavernous breathing, or breathing 
of an amphoric type. The presence of a cavity, however, is often diffi- 
cult to recognize, because of the relation to the surrounding structure 
or because of fluid contents. If the lung about it is the seat of con- 
solidation, the physical signs of this consolidation may over-ride the 
signs of a cavity. If compensatory emphysema surrounds the cavity, 
it may be almost impossible to recognize it. Moreover, the contents 
of the cavity render the recognition of its presence difficult. If it con- 
tains a large amount of fluid, the signs of consolidation alone may be 
present. Much attention has been paid to the recognition of cavities, 
and some methods have been proposed by which it is thought they can 
be distinguished. While it is a satisfaction to determine exactly the 
presence and location of a cavity, it is not an essential to diagnosis. 
To confirm the presence of an excavation, even if the physical signs 
point to its occurrence, the diagnosis should be controlled by exami- 
nation of the sputum. If, on such examination, yellow elastic tissue 
is found, the presence of a cavity is more probable. The methods 
employed to determine their presence absolutely have been named after 
the observers who devised them. 

First, WintricNs change of sound. If the cavity communicates with 
a large column of air in the bronchus, and percussion is employed with 
a moderate degree of force, the note will change as the patient alter- 
nately opens and closes the mouth. If the mouth is open wide, the 
sound is louder and more distinctly tympanitic and higher in pitch. 
If the mouth is closed, the sound is correspondingly lessened and not 
so tympanitic. Indeed, sometimes a sound is obtained with scarcely 
a trace of tympany. This change of sound is in all probability due to 
change in the resonant cavities in the upper respiratory tract. It must 
not be confounded with " Williams' tracheal tone," which can be 
elicited near the junction of the clavicle and sternum on the left side, 
in cases of consolidation of the underlying portion of the lung, partic- 
ularly if the force of the blow is directed toward the trachea. Strong 
percussion is necessary to bring out Williams' tone. 

Second, interrupted change of sound, also described by Wintrich, is 
distinguished from the simple change, in that it occurs in different 
positions of the body. It may be heard when the patient is in an 
upright position, and disappear when he assumes the recumbent posture ; 
01* the converse may be true. The change in position changes the 
relation of the bronchus to the cavity, on account of which the varying 
tympanitic sound is produced. 



DISEASES OF THE LUNGS AND PLEUBJE. 515 

Third, Gerhard? s change of sound. This change depends upon the 
alteration of the level of the fluid when the patient assumes the up- 
right, or the dorsal position. It is not necessary that the cavity com- 
municate with the large bronchus. It is a positive symptom of a cavity, 
but rarely present. The sound changes in pitch and in the degree of 
tympany. It may be absolutely dull over the lower part of the cavity 
when the upright position is assumed, because the fluid gravitates to 
this portion and comes in contact with the chest-wall. 

Fourth, Friedreich's respiratory change of sound. Respiratory per- 
cussion. (Da Costa.) The pitch of the sound becomes higher at the 
end of a deep inspiration. It depends upon increased tension of the 
chest-wall and lung-tissue, and the wall of the cavity, during the act 
of inspiration. It may be a source of confusion, which is obviated by 
percussing at the same stage of the breathing each time, or percussing 
only on superficial breathing. 

Fifth, Seitz has called attention to a form of breathing named meta- 
morphosing. Inspiration begins harshly bronchial, then becomes faintly 
bronchial, the latter sound being heard also in expiration. It is said 
to be a sure sign of cavity. 

Resume. The student must bear in mind in auscultation to note : 
(1) If the sounds are increased or diminished in intensity ; (2) the 
rhythm of the inspiratory and expiratory sounds ; (3) if the respiratory 
murmur is replaced by bronchial breathing or its modification ; (4) the 
presence of new sounds (rales and friction) ; (5) the voice-sounds. 

Mensuration. By mensuration or thoracometry, the results secured 
by palpation are confirmed more accurately. The size and the degree 
of expansion of the chest are ascertained. Hence the circumference 
and diameter of the chest are determined and the differences in the 
shape and movement of two sides made manifest. If the measure- 
ment is taken from day to day, it can be graphically recorded by 
tracing sections on paper, and delicate changes can thus be definitely 
ascertained. The circumference of the chest is measured by means of 
the ordinary tape-measure or by metal tapes joined together by a 
hinge. The latter can be made to fit the circumference of the chest 
accurately, and are essential in order to transfer the section to paper. 
The middle of the hinge is held firmly over the spinous process of the 
vertebra, while the two limbs are carried around the chest, moulded 
to all inequalities, and crossed in front, one above the other ; a mark 
is made on each Avhere it crosses the middle line. Measurements 
should be taken at about the level of the nipples, and two inches below 
them, and care should be taken to have the level the same in front and 
behind. They should be taken in full inspiration and expiration, and 
in repose. The outline secured by this method need not be disturbed, 
as by flexion on the hinges we are enabled to remove it intact. The 
tapes are carefully transferred to a sheet of paper, on which imaginary 
diameters have been marked. After fixing the corresponding points of 
the tapes on the lines of the respective diameters, the outline can then 
be traced. 

Woillez's cyrtometer is a chain with links which is used to ascertain 
the exact circumference. The diameter of the thorax is secured by 



51C SPECIAL DIAGNOSIS. 

means of caliper compasses. The antero-posterior diameter should be 
taken on a level with the nipple and the insertion of the second rib 
behind ; the transverse diameter at the highest points of the axillae. 
The length of the chest may be ascertained by measuring in the mid- 
clavicular line from the clavicle to the border of the ribs. It is im- 
portant to remember that the right side of the chest measures a little 
more than the left in people who are right-handed. 

The respiratory capacity is estimated by measurement of the circum- 
ference of the chest. This is secured by taking the measurement at 
the end of complete expiration and then at the end of complete inspi- 
ration. In health the difference between the two should be from five 
to ten centimetres (two to four inches). If the expansion is less than 
two inches, it is considered deficient by insurance companies, and the 
risk is not regarded as first-class. The expansion is less in women. 
In taking the measurement the observer must be particular to keep the 
terminal portion of a tape-measure fixed in the median line of the 
structure. The other portion is to be held in the hand, so as to move 
with inspiration and expiration. Always mark in advance the ante- 
rior mesial line and note the exact level at which measurements are 
made when they are taken daily. Deficiency of chest-expansion not 
only indicates the presence of a local morbid process — notably incipi- 
ent tuberculosis, but it also indicates lack of strength and of muscular 
development, of physiological deficiencies, rather than physical, and is 
an unerring guide to the need of respiratory gymnastics. 

Spirometry. By means of the spirometer Dr. John Hutchinson 
has been able to estimate the quantity of air taken in with each inspi- 
ration and discharged with expiration. By it the respiratory or vital 
capacity is estimated. The data ascertained are not of much diagnostic 
significance, although if measurements are made from day to day we 
may be able to estimate the extent of recovery from disease of the lung 
which was incapacitated. When, however, there is an important 
diminution of lung-capacity, tuberculosis may be suspected, before 
subjective and objective signs warrant a diagnosis. We can also esti- 
mate the degree of interference with breathing by disease below the 
diaphragm. Spirometry is of particular value because it shows in a 
graphic manner the need for respiratory gymnastics. By means of 
Waldenburg's pneumotometer the respiratory pressure of air on inspi- 
ration and expiration is determined. Expiratory pressure is dimin- 
ished in emphysema, and the degree of diminution may furnish a clue 
to the severity of the disease or the degree of improvement. It is 
to be remembered that the expiratory pressure always exceeds the inj 
spiratory pressure in health by as much as 20 to 30 millimetres, accord- 
ing to Waldenburg. It is natural to find that inspiratory pressure is 
lessened in stenosis of the air-passages, in phthisis and in pleural effu- 
sions, although it is not of diagnostic significance. 

The following measurements, secured by laborious investigation, are 
exeellenl criteria from which pathological inductions can be made. 



DISEASES OF THE LUNGS AND PLEURAE. 



517 



Measurements of the Chest and Lung Capacity. 

(Otis, Boston Medical and Surgical Journal, 1895.) 
Table I. — Chest Measurements. 



Girth , muscular. — Men : 

Average of Dr. E 0. Otis, 1000 measurements, 

between sixteen and forty years of age 
Average of Dr. Hitchcock, of Amherst College, 

8000 measurements ...... 

Average of E. Hitchcock, J., of Cornell College, 

15,000 measurements ..... 

Girth, muscular. — Women: 

Mt. Holyoke and Wellesley students. Measure- 
ments of Miss Wood and Dr. Mary Colton 
Chest, respiratory. — Men: 

Average of Dr. E. O. Otis, 1000 measurements . 
Chest, respiratory. — Women : 

50 per ct. of 1500 of Wellesley students, Miss Wood 
Depth of chest. — Men : 

Average of Dr. E. O. Otis, 1250 measurements in 

repose and 362 inflated ..... 

Depth of chest. — Women : 

50 per ct. of 1500 students at Wellesley, Miss Wood 
Breadth of chest. — Men 

Average of Dr E. O. Otis, 400 measurements 



Repose, 
inches. 


Inflated, 
inches. 


Difference, 
inches. 


34.0 


36.1 


2.1 


34.6 


36.5 


1.9 


34.5 


36.3 


1.8 


29.5 


31.5 


3.0 


31.1 


33.1 


2.0 


24.6 


27.2 


2.6 



Table II. 



Men 



6.9 

9.9 
Capacity of Lungs. 



8.3 



10.8 



Average of Dr. E. O. Otis, 1000 measurements 

Hitchcock, 8000 measurements ........ 

Hitchcock, Jr., 15,000 measurements 

Women : 

Mt. Holyoke and Wellesley students, measurements of Miss Wood 

and Dr. Mary Colton 

50 per cent, of 1500 Wellesley students, Miss Wood . 



0.8 



0.9 



Cubic inches. 

240.6 
, 230.0 
, 236.6 



145.8 
150.3 



Table III. — Comparison of the " vital " or lung capacity and the amount of 

air expelled after an ordinary quiet respiration. 

Average of Dr. E. O. Otis, 150 measurements. 



Vital capacity, or the amount of air exhaled after a full inspiration 
Amount of air exhaled after an ordinary quiet respiration 
Difference, or " complemental " or " reserve " air 
Difference as given by Hermann ...... 

Average Lung Capacity for Height (Otis). 



Cubic inches. 
. 230.5 
. 129.3 
. 101.2 
. 97.6 



Height. 

66 to 67 inches inclusive. 

167.7 to 170.3 centimetres. 

67 to 68 inches inclusive. 

170.3 to 172.8 centimetres. 

68 to 69 inches inclusive. 

172.8 to 175.4 centimetres. 

69 to 70 inches inclusive. 

175.4 to 177.9 centimetres. 

70 to 71 inches inclusive. 

177.9 to 180.5 centimetres. 

71 to 72 inches inclusive. 

180.5 to 183.0 centimetres. 

General average . . 



Lung capacity. 

231.62 cubic inches. 
3797 cubic centimetres. 
237.10 cubic inches. 
3903 cubic centimetres. 
244.44 cubic inches. 
4007 cubic centimetres. 
259.34 cubic inches. 
4250 cubic centimetres. 
261.38 cubic inches. 
4284 cubic centimetres. 
261.34 cubic inches. 
4284 cubic centimetres. 



Average for each inch or 
centimetre in height. 

3. 4 -4- cubic inches. 
22.4 cubic centimetres. 

3.46 cubic inches. 
22.7 cubic centimetres. 

3.5 cubic inches. 
23.06 cubic centimetres. 

3.66 cubic inches. 
24.06 cubic centimetres. 

3.64 cubic inches. 
23.9 cubic centimetres, 

3.5 cubic inches. 
23.03 cubic centimetres. 



3.52 cubic inches, for each inch of height. 
23.19 cubic centimetres, for each centimetre of height. 



518 SPECIAL DIAGNOSIS. 

Powel lays great stress upon the fact that in phthisis the inspiratory 
capacity is diminished, but the expiratory power remains normal. 

Combination of Physical Signs. In order to determine the physi- 
cal condition of the lung, it is necessary to draw conclusions from the 
results obtained by all the methods of physical examination. It is the 
exception that any one sign is pathognomonic of a physical condition. 
If the student will glance over the abnormal physical conditions which 
may take place in the lung, he will find that they may be divided, 
first, into physical changes in the lung proper, and, second, into physi- 
cal changes in the pleura. With regard to the lung, it will be further 
noted that the changes are due to an increased amount of air or to a 
diminution in the amount of air. 

Increase in the amount of air may be general, unilateral, or local, 
and is indicated by a combination of physical signs which are usually 
unerring. On inspection (a) enlargement, general, unilateral, or local ; 
(b) increased action in general emphysema, although with diminished 
respiratory excursion ; when unilateral or local, increased action and 
increased expansion (compensatory emphysema). On palpation, in- 
spection confirmed, and vocal fremitus diminished when the increased 
amount of air is general, slightly increased when it is unilateral or 
local. On percussion in each instance exaggerated resonance or tym- 
pany. On auscultation, when general (emphysema), feeble respiratory 
murmur, with prolonged expiration ; when unilateral or local, exagger- 
ated respiratory murmur. The difference in the physical signs of 
increased amount of air is not due to the difference in quantity, but 
to the associate physical condition and the force of the movement of 
the air. The diminished expansion and feeble respiratory murmur in 
emphysema are due to inability to exhale the air because of the dimin- 
ished elasticity of the lung, while the bronchioles occluded from bron- 
chitis lessen the fremitus. In cavities — local increase of air — the 
physical condition of the .tissue which surrounds them modifies the 
physical signs. 

Decrease in the Amount of Air. The diminution in the amount of 
air from change in the physical condition of the lung is due to consoli- 
dation or to collapse. The latter occurs when the bronchus is obstructed, 
the former in congestion, pneumonia, gangrene, abscess, forms of tuber- 
culosis, and hemorrhagic infarct. The physical signs are the same 
under all circumstances, except in collapse : expansion lessened, fremi- 
tus increased, dulness, bronchial breathing. The signs vary with the 
degree of consolidation as follows : Slight increase to greatly increased 
fremitus, impaired resonance to complete dulness, broncho-vesicular to 
bronchial breathing. In tuberculosis there may be flattening of the 
chest-wall, but otherwise the signs are the same. The presence of 
new sounds depends upon the amount of secretion or fluid, as is the 
case when there is increase of air in the part. 

Broadly speaking, therefore, in affections of the lung proper, the two 
conditions just mentioned must be differentiated — air increased, air 
diminished. We do not refer to bronchitis, because no physical change 
takes place in the lung, and the signs depend upon the amount of 
fluid in the tubes. 



DISEASES OF THE LUNGS AND PLEURjE. 519 

The Pleura. If satisfied that the physical condition is not due to 
change in the lung structure, the state of the pleura must be investi- 
gated. Here, too, the physical condition may be due to an excessive 
accumulation of air or to an accumulation of fluid or solid material. 
In effusion there is enlargement of the affected side, diminished move- 
ment, diminution of fremitus and of vocal resonance. When air is 
present, however, there is tympany ; when fluid, there is dulness on 
percussion. 

The problem may, however, be looked at from another side. 1. The 
percussion-note is tympanitic and indicates that there is an increased 
amount of air. Is this in the pleura or in the lung ? If in the pleura, it 
can only be unilateral, and is recognized by diminution of the move- 
ment and of fremitus, as against increased movement and fremitus 
when due to unilateral increase of air in the lung proper (compensatory 
emphysema). 2. The percussion-note is dull and iudicates the absence 
of air. Is this in the pleura or in the lung ? A distinction between 
consolidation and pleural effusion must be made. In consolidation 
there are increased fremitus, increased vocal resonance, bronchial breath- 
ing, and dulness on percussion. There may or may not be contrac- 
tion. In pleurisy with effusion, diminished or absent movement, absent 
fremitus and resonance, dulness on percussion, feeble, distant, or absent 
breath-sounds. The distinction of the two physical conditions seems 
easy, and yet the physical signs may not be sufficiently definite to 
warrant a positive conclusion. There are cases in practice in which it 
is almost impossible to determine which is present. It has been stated 
previously that bronchial breathing may be present in pleural effu- 
sions. To add to the difficulty in certain cases of consolidation it may, 
however, be absent, and so may the vocal fremitus and resonance. 
Apart from the associate general and local symptoms, we must look 
to two methods of corroborative proof of the presence of fluid. First, 
exploratory puncture ; and, second, displacement of organs. The former 
has been spoken of. The latter includes displacement of the heart to 
the right or to the left, depending upon the seat of the effusion ; dis- 
location of the liver ; and, in cases of left pleural effusion, obliteration 
of the half -moon space (Traube's line). 

Sputum. 

This term is applied to all the products of secretion of the mucous 
membrane of the respiratory tract, and other substances that may be 
brought up through the respiratory tract. The characters of sputa in 
disease vary with the part affected, as well as with the pathological 
nature of the disease. It is always well to examine each specimen 
both macroscopicatty and microscopically. 

Method of Collection. Sputum that is to be examined should 
be collected in perfectly clean vessels, containing no fluid, preferably 
in glass or white earthenware spittoons, and care should be exercised 
against the entrance of any extraneous substances, as tobacco or parti- 
cles of food from the mouth, or from outside sources, or from the 
stomach through vomiting. Tobacco, prunes, and bread crusts are at 



520 SPECIAL DIAGNOSIS. 

times mistaken for blood. It is also necessary to see that the matter 
sent for examination is derived from the lungs, and is not simply the 
oral and faucial accumulation. If practicable, the mouth and pharynx 
should be first rinsed with a warm alkaline solution. The true sputum 
is coughed up. 

AVe usually require in the examination one or two glass dishes or 
plates, a large and a small piece of window-glass, mounted needles, and 
forceps ; for microscopic work, in addition to these, a good microscope 
and accessories, and certain staining fluids. Sputa which upon exam- 
ination has been found to contain tubercle bacilli should not be allowed 
to dry in the air, but should be thoroughly mixed with a 1 : 20 car- 
bolic acid solution, or a 6 per cent, formalin solution should be added 
to the sputa after the examination is completed. 

In describing sputum we note the quantity in twenty-four hours ; 
its color, odor, specific gravity, its composition and consistency, whether 
mucous, purulent, mucopurulent, frothy, watery, bloody, tenacious or 
viscid, and whether it is made up of separate layers or is homogeneous. 

The quantity in twenty-four hours varies from a few c.c. to even 
1000 c.c, as in a discharging empyema. 

The color changes with the composition and the nature of the disease. 
Thus, in acute bronchitis and oedema of the lung it is white ; in puru- 
lent sputa, no matter what the cause, it is yellow or greenish-yellow ; 
in pneumonia, " rusty ;" in abscess of the liver with amoebse character- 
istics, brownish-red or like " anchovy sauce." 

The odor is characteristic in a few cases only. That of bronchiec- 
tasis, gangrene, and putrid bronchitis is particularly heavy and fetid — 
a characteristic which renders its origin almost unmistakable. 

The reaction is always alkaline. 

The specific gravity may vary from 1.0043 (mucus sputum) to 
1.0375 (serous). (Von Jaksch). 

Varieties of Sputum. Mucus sputum, on account of the mucin, 
is usually glairy, clear, and tough. It is seen in acute bronchitis in 
the early stage, and in oedema of the lung. In health a small amount 
of mucus is expectorated, which in cities and smoky towns is apt to 
contain black pigment-particles, due to inhaled soot. 

Purulent sputum is composed almost entirely of pus. Typical 
purulent sputum is that from an empyema discharging through a bron 
chus. It may also occur in bronchiectasis, chronic bronchitis, abscess 
of the lung, of the liver, or more rarely of the mediastinum, discharging 
through a bronchus ; or it may be the discharge of a tubercular 
vomica. The special condition can usually be determined by micro- 
scopical examination and the accompanying symptoms and signs. 

Mucopurulent Sputum. It is most common to have mucus and 
pus mixed together in varying proportions, and then it is termed 
mucopurulent. Such sputa may be found in the same conditions as 
purulent sputa. AVhen flat, coin-shaped masses are formed, sinking 
to the bottom if the vessel contains water, as in phthisis and chronic 
bronchitis, it is known as "nummular" sputum; or it may be more 
spherical, and is then called " globular." At times the sputa may be 
scon to separate into three distinct layers, the upper frothy, mucopuru- 



DISEASES OF THE LUNGS AND PLEUEJE. 521 

lent, greenish-yellow, or dirty-green, sometimes lumpy, sometimes 
composed of shreds ; the middle thin and watery, with shreds from 
the upper layer ; and the bottom layer, apparently made up of pus 
and debris, opaque, and without air-bubbles. It points to gangrene 
of the lung in most instances, but may also occur in bronchiectasis. 

Watery or serous sputum is the result of oedema of the lung. 
Such sputum, also called albuminous expectoration, is discharged after 
paracentesis of the chest. Beginning during or as late as two hours 
after the operation, from one to three pints may be discharged in a few 
hours. 

Bloody Sputum — Haemoptysis. As blood in sputum is always 
of importance, the entrance of substances as mentioned above, which 
simulate it in appearance, should be guarded against. It may be seen 
in greatly varying quantities and have many different sources, and it 
may be of slight or grave significance. It may come from the gums, 
nose, pharynx, or larynx, and in all cases such sources should be exam- 
ined. Again, there may be cases in which bleeding from the stomach 
(hrematemesis) or oesophagus simulates hemorrhage from the lungs, 
but still more often people speak of vomiting blood that really has 
come from the lungs. Usually that from the lungs is much more 
frothy and bright-red, Avhile that from the stomach is darker and 
acid, and may contain particles of food. Diagnosis is more difficult 
when some blood from the lungs is first swallowed and then vomited. 

Usually there is a distinct history of preceding cough, and for some 
time afterward small amounts of blood continue to be expectorated. 
(See Lungs ; Hemorrhage.) 

Small amounts of blood streaking the mucus sputum or appearing 
in small clots often come from the throat or nose or upper air-pas- 
sages, but may come from the lungs. Mucopurulent sputum streaked 
with blood is frequently indicative of phthisis. In pneumonia the 
rusty sputa are the result of an admixture of mucus and blood, and 
usually contain small air-bubbles. When the blood-coloring matter 
is changed there may be a yellowish or greenish tinge. In certain 
cases of chronic pneumonia, in which the blood remains longer in the 
lung-tissue, the expectoration has a darker color. The same color may 
be observed when there is a slight leakage from an aneurism. Pneu- 
monia accompanied by expectoration of large amounts of blood is often 
of tuberculous origin. Blood may be mixed with the greenish expec- 
toration of gangrene. According to Finlayson, this is especially true 
in children. In chronic valvular disease of the heart, and in oozing 
from aneurism, frothy mucus containing more or less blood is com- 
monly seen. " Currant-jelly " sputa are more or less characteristic of 
malignant growths of the lungs, while the expectoration from a liver 
abscess with amoebse is reddish-brown in color, from the mixture of 
blood, pus, and bile-elements, and is not unlike " anchovy sauce." 
We may have hemorrhage from the lungs as part of a general hemor- 
rhagic tendency, as in purpura and hemorrhagic smallpox ; in so-called 
" vicarious menstruation " there may be haemoptysis. But a patient 
presenting such symptoms should be examined with the greatest care, 
to exclude actual pulmonary complication. When great quantities of 



522 



SPECIAL DIAGNOSIS. 



blood are expectorated we suspect tuberculosis of the lung, aneurism, or 
cardiac valvular disease. 

The unaided eve may distinguish other foreign substances, such as 
fibrinous and spiral casts of the bronchi or trachea ; but full considera- 
tion of them will be given further on. 

Microscopical Examination of the Sputum. (See Fig. 143.) 
White blood-corpuscles, usually of the polymorphonuclear variety, 
are present in all sputa, but in varying numbers and size. They are 
most abundant in purulent sputa. Often they contain fat-drops and 
pigment-particles. In stained preparations of sputa in cases of acute 
croupous pneumonia, influenza, pneumonia, or phthisis, frequently 
many of the leucocytes contain large numbers of organisms — i. e., pneu- 
mococci, influenza bacilli, or tubercle bacilli. 

Red blood-corpuscles are to be found in most sputa. They 
may be so few as not to give a red color. The source is often high up 
in the respiratory tract. When they are present in large numbers the 
sputum is more or less tinged, and in haemoptysis it is almost wholly 
made up of red cells. Usually each cell is well preserved, but they may 
appear as pale bodies or as rings, the pigment remaining in the sputum 
as pigment-particles or as crystals of haematoidin, as in pneumonia. 

Eosinophile cells are frequently found in large numbers in the 

sputum in cases of asthma. They are also present in the sputum in 

acute and chronic bronchitis and in phthisis. Their presence in the 

sputum in cases of phthisis is considered by Teichmuller to be of 

favorable import. 

Fig. 143. 




• ., <M 



V3> 



-■s 



,' ■!■ - -I 



W 



'& 



Various objects from sputum. 1, squamous epithelium ; 2, red blood-corpuscles ; 3, polynuclear 
leucocytes , 4, alveolar cells : 5, myelin-cells ; 6, pigment-cells ; 7, elastic-tissue fibres ; 8, squamous 
cells ; 9, hsematoidin-crystals ; 10, phosphate crystals : 11, fungi ; 12, fat-globules ; 13, free pigment. 
(Original observation.) 



EPITHELIUM. Two general varieties are found in the sputum — squa- 
mous and cylindrical. The former comes from the mucous membrane 
of the mouth, the tongue, tonsils, true vocal cords, and perhaps from 
tli" salivary and .small bronchial glands. It has no clinical impor- 
tant. (See Fig. 143.) 



DISEASES OF THE LUNGS AND PLEURjE. 



523 



Cylindrical cells in sputum are rarely perfect. It is uncommon to 
find the cilia intact, and still more so in motion, while the body of the 
cells is likely to be changed. They are found in inflammations of 
the trachea and bronchi, or the posterior nasal fossa — a locality where, 
it must be remembered, ciliated epithelium exists. 

" Alveolar " epithelium, so called, when found in the sputum, 
is more important than the above, as different observers consider its 
presence to have more or less clinical significance. The cells are ellip- 
tical or round, somewhat larger than white corpuscles, with a single 
nucleus, which is indistinct without the addition of acetic acid. The 
protoplasm is granular and contains particles of iron-dust, carbon, or 
blood-coloring matter, and often fat-drops. The cells may also have 
undergone complete fatty degeneration, and they have been considered 
the source of my elm-drops in the sputum. 

Bizzozero has shown that alveolar epithelium not only occurs in 
almost all pulmonary affections, but also at times in normal sputum. 

Detection. A small bit of sputum is placed on a microscope-slide 
and a cover-slip applied. Examine with varying powers, and again, 
after acetic acid is added, stain the cells with an aqueous solution of 
m ethyl ene-blue. 

Frequently in cases of heart disease with failing compensation, espe- 
cially where the mitral valve is affected, the alveolar cells may contain 
large amounts of blood pigment. 

Giant cells have been found in the sputum of phthisis cases. 

Elastic Fibres. As the presence of elastic fibres in sputa is of 
much import, denoting destruction of the lung-tissue, bronchi, or the 
larynx or bloodvessels, their presence from food remaining in the 
mouth must be especially guarded against. They may be mistaken 



Fig. 144. 




'iff - 
# 

Elastic fibres of lung-tissue obtained from sputa after digestion in caustic soda. 
(Drawn by Dr. John Wilson.) 



for fat-crystals. They are found as single threads in bundles, or show- 
ing an alveolar arrangement. They are to be recognized by the double 
contour and curling ends, and at times by their alveolar arrangement. 
They may be due to tuberculosis, abscess of the lung, bronchiectasis, 
gangrene of the lung, pneumonia (von Jaksch), and rarely to destruc- 
tive diseases of the larynx. In a very great majority of cases they are 



524 SPECIAL DIAGNOSIS. 

due to tuberculosis. It is uncommon to find them in gangrene, proba- 
bly because, as Traube first suggested, they are destroyed by a ferment. 
(See Fig. 143.) 

Elastic tissue from the alveoli often shows the diagnostic alveolar 
arrangement ; the fibres that form a bronchus are branched ; those 
from eroded artery appear in the form of a network, or the fibres are 
bound together. (See Fig. 144.) 

Detection. The method employed by Osier, modified from Sir Andrew 
Clark's, is the best. A small amount of the thick, purulent portions 
of sputiun is pressed out in a thin layer between two pieces of plain 
Avindow-glass, 15x15 cm. and 10x10 cm. The particles of elastic 
tissue appear on a black background as grayish-yellow spots, and can 
be examined in situ under a low power. Or the upper piece of glass is 
slid off till the piece of tissue is uncovered, when it is picked out and 
examined on a microscopic slide, first with a low power, as the one or 
one-half inch objective, and then with a higher power. At first there 
will be some difficulty in distinguishing with the naked eye between 
elastic fibres and particles of bread or milk globules, or collections of 
epithelium and debris, but with practice such mistakes can be avoided, 
and the microscope always reveals the difference. This method is 
much easier of accomplishment and quite as satisfactory in results as 
the one generally employed— boiling an equal quantity of sputum and 
solution of caustic potash (8 to 10 per cent.) for a short time, and then 
allowing it to stand for twenty-four hours in a conical glass. The 
elastic tissue remains intact and is found in the sediment. 

Connective tissue and cartilage, in fragmentary bits, are rare 
constituents of sputum. The former may occur with abscess or gan- 
grene of the lung, and the latter when there is ulceration of the 
larynx. 

Fibrinous Coagula. These striking, tree-like bodies are found 
in the sputa of plastic bronchitis, and at times in that of pneumonia, 
phthisis, and in diphtheria and croup when there has been an exten- 
sion into the bronchi. They are usually mixed with mucus, and are 
rolled up into a mass. Their peculiar form is best seen when they 
are washed and unravelled in water. They are then seen to be a com- 
plete mould of a small bronchus with its ramifications. The size varies 
greatly. They may be many centimetres long. In fibrinous bron- 
chitis the size and shape of the moulds in different attacks may be 
exactly similar, as if they came from the same bronchus. They are 
grayish-white in color, hollow, and on transverse section are seen to 
be made up of cast upon cast. Leucocytes, blood-cells, and alveolar 
epithelium are found hi the meshes by the microscope, and at times 
Charcot-Leyden crystals and Curschmann's spirals also. They are 
almost pathognomonic of fibrinous bronchitis. When they occur in 
any number in pneumonia they make the prognosis unfavorable. 
Blood-casts of the smaller bronchi have been found in cases of haemop- 
tysis. They are rare, and have no apparent connection with the fibrous 
coagula. 

Spirals. Under this name are included spiral bodies that are 
found in the sputa of bronchial asthma, and occasionally in that of 



DISEASES OF THE LUNGS AND PLEURAE. 525 

pneumonia and capillary bronchitis (von Jaksch), and chronic pulmo- 
nary tuberculosis (Vierordt). At the beginning of an asthmatic attack 
tough rounded balls are expectorated — " perles " of Lsennec-- which, if 
freed from the mucus surrounding them and spread out on a glass with 
a dark background, may be seen by the naked eye to have a twisted 
spiral form. With the aid of the microscope they are found to be 
made up of spirally arranged mucin in a more or less tight twist, with 
many cells from the alveoli and bronchi. In some of these spirals a 
shining central thread runs through the entire length like a core, re- 
markable for its clearness and its high refractive index. The fine 
fibres composing the spiral may be closely arranged or not. Epithe- 
lium and Charcot-Leyden crystals may be found lying among the coils. 
The main constituent of the spirals is mucin, and Osier has suggested 
that the central thread is made up of transformed mucin. On the 
other hand, von Jaksch believes it to be chemically distinct from the 
mucin spiral and to approach rather to the character of fibrin. Vier- 
ordt considers it either made of tightly twisted central fibres or to be 
an optical image of a core-cavity. They are probably the result of an 
acute bronchiolitis. Why they should assume this remarkable form 
is still an open question. It has been suggested (Osier) that the 
ciliated epithelium of the bronchi may have a rotary action, and their 
action, combined with the spasm of the bronchioles, causes the spiral 
formation. 

Sections for Microscopical Examination. Schmidt (Zeitschrift 
f. him. Med., 1892, p. 476) fixes sputum in J per cent, salt solution 
saturated with mercuric chloride, hardens in alcohol, and sections in 
the usual manner. For hardening sputum Zenker's fluid has been 
found most satisfactory. After hardening the sputum is embedded in 
paraffin and cut. In many cases it is advisable to roll up the sputum 
in a little ball before fixation. For the study of spirals thick pieces 
should be embedded in celloidin ; for the study of the cellular elements, 
thin sections are embedded in paraffin. 

Sections of sputum with mucin swell when treated with watery 
solutions of the dyes ; hence the celloidin should be first removed to 
prevent folding of the sections. All specimens of sputum, except the 
very thin ones, can be prepared in the manner described. 

The spirals are best stained with Weigert's fibrin-method ; they 
stain blue. Yet they — i. e., the central threads — are not fibrin : (1) 
Because they are perfectly homogeneous ; (2) they assume a violet 
color after prolonged staining — fibrin is always blue ; (3) unformed 
blue masses are found which could only be compact mucin masses ; 
(4) their specific mucin reaction with thionin ; (5) the greenish color 
assumed when Ehrlich's triacid stain, as modified by Babes, is used. 
(See Fig. 145.) 

That there is a connection between the spirals and Charcot-Leyden 
crystals seems very probable, as the latter are absent from the sputum 
at the beginning of an attack of bronchial asthma ; but if a portion of 
such sputum is allowed to stand for twenty-four to forty-eight hours, 
taking care that evaporation does not take place, crystals will be found. 
As has been said, the crystals are often found among the spirals, and 



526 



SPECIAL DIAGNOSIS. 



this when they are seen nowhere else. Later on the spirals disappear, 
but crystals derived from them (?) continue to be expectorated. (See 
Fig. 145.) 

The method of examining for spirals is as given above. 



Fig. 145. 




Spirals from bronchial tubes. X 80. (Alter Leyoen. 



Crystals. Charcot-Leyden, cholesterin, hsematoidin, fatty, tyrosin, 
oxalate of lime, and triple phosphate crystals are to be found in sputa 
under various conditions. 

Charcot-Leyden crystals are octahedral, sharply pointed, color- 
less or slightly bluish, soluble in warm water, alkalies, and acetic and 
mineral acids. The practised, unaided eye may recognize these as 
small yellowish bodies, not unlike grains of sand; under the micro- 



DISEASES OF THE LUNGS AND PLEURJS. 527 

scope they are unmistakable. Their size varies greatly. They occur 
most abundantly during (invariably) and after an attack of bronchial 
asthma ; they have also been seen in sputa of acute and chronic bron- 
chitis and tuberculosis. They are identical with crystals found in 
semen, feces, and leukemic blood and bone-marrow. Their connec- 
tion with spirals has been mentioned above. Schreiner considers them 
to be the phosphate of an unknown base, which Ladenburg and Abel 
think may be identical with sethyleninim or di-aethyleninim. This 
identity, however, is disputed by Th. Kohn. 

Detection. Examine the sputum of an asthmatic patient a day or 
two after the beginning of an attack for round, hard, yellowish bodies, 
and place these under the microscope with different powers. They 
are readily recognized. (See Fig. 146.) 




Charcot crystals. (Scheube.) 

Cholesterix Crystals. These crystals are similar to those of 
cholesterin found elsewhere, being thin rhombic plates, often with 
irregular corners and high refractive index. They are soluble in ether ; 
and, when treated with dilute sulphuric acid and tincture of iodine, 
become violet, blue, or green, and then red. They may be present in 
the sputum of tuberculosis, abscess, and hydatid abscess of the lung, 
and in pus from an abscess of another organ, as the liver. They have 
but little clinical significance. 

ELematoidix Crystals. Haematoidin crystals are at times recog- 
nizable by the naked eye as distinct spots of yellowish or brownish- 
red color. Under the microscope they have a brownish-yellow or 
ruby-red color, and are either in the form of small rhomboid prisms or 
of fine needles, single or arranged in bunches of various shapes, or as 
free pigment-particles without crystalline form ; smaller particles may 
be contained within a leucocyte. Their presence indicates that blood 
has remained in the respiratory tract for some time before being expec- 
torated, or that an abscess has discharged into a bronchus. They occur 
in phthisis, following hemorrhage ; in thoracic aneurism when blood 
is oozing into the lung ; in gangrene ; in abscesses discharging through 
a bronchus. Von Jaksch states that when the crystals are contained 
in cells there has been a preceding hemorrhage, but that when there 
is considerable free hsematoidin one infers that an abscess of a neigh- 
boring organ has discharged into the lung. 



528 SPECIAL DIAGNOSIS. 

Fatty Crystals. Crystals of margaric acid occur as long, thin 
needles, greatly curved or bent at one end like a fish-hook, and either 
singly or in bundles. They are found in unhealthy pus — as in gan- 
grene, putrid bronchitis, bronchiectasis, and tuberculosis ; in the plugs 
formed in inflamed tonsils ; and in purulent sputum in general which 
is allowed to stand in a warm place. They dissolve in ether and boil- 
ing alcohol ; this characteristic, together with the regularity of their 
curve, should distinguish them from elastic fibres, with which they 
are sometimes confused by beginners. 

Tyeosix crystals have been found in the sputum of putrid bron- 
chitis and empyema discharging into the lung, and usually in conjunc- 
tion with leucin. They are most abundant in sputum that has been 
allowed to stand for some time. Under the microscope they appear 
as fine needles, and can be mistaken for fatty crystals. They are with- 
out diagnostic importance. 

Oxalate of lime and triple phosphates have been noted 
occasionally in sputa ; the former in a case of diabetes, and also in an 
asthmatic ; the latter occur only in alkaline sputa, as they are soluble 
in acids. 

Uric acid crystals have been observed by Moore in the sputum 
of a gouty patient. 

Concretions are rarely present in the sputum. They arise usually 
from the bronchial glands or lungs, from foci of tuberculosis which 
have become healed with the deposition of lime-salts. They may be 
single or multiple. Hievoiles reports finding tubercle bacilli in the 
centre of one of these concretions. 

Corpora Amylacea. Starch-like bodies have been found in the 
sputum after pulmonary hemorrhage and in that of pulmonary gan- 
grene. They have the shape of starch-corpuscles, and sometimes give 
the amyloid reaction with iodine or iodide of potassium. They are 
at present without clinical significance. 

Parasites. 

A. Animal Parasites. Echinococcus cysts are to be found in spu- 
tum, generally broken into fragments, and only very rarely in a per- 
fect whole, when there is rupture of a cyst of the liver or lung into a 
bronchus. Scolices and free booklets from the same may be recog- 
nized, and pieces of the cyst-wall will be known by their remarkable 
formation. Their presence is of great clinical value. 

Infusoria have been found in the expectoration from gangrene of 
the lungs. They belong to the monad and cercomonad varieties. 

Distoma haematobium eggs may occur in sputa when the lung-tissue 
is broken down by its presence, the eggs being thrown off in the sputum. 

The distoma Westermanii or pulmonale is found in the sputum in 
Japan in certain cases resembling phthisis. Both the worm and the 
ova may be present in the sputum. 

Amceba Dysenteries (Amoeba Coll). Of far more interest and im- 
portance is the presence of this parasite in the expectoration. A full 
description of the amoeba will be given in the article on Dysentery. 



DISEASES OF THE LUNGS AND PLEVRJE. 529 

They are the same in every respect when found in the sputum, except 
that they are often slightly larger. The sputum containing the amoeba 
is partly diffluent, tenacious, frothy, bright red in color at first, due to 
the presence of blood, and later brick or brownish-red, sometimes bile- 
stained. Small yellowish-white cheese-like particles are seen. Upon 
exposure to the air the sputum becomes thin, syrupy, and oily, and it 
then looks much like anchovy sauce. The sputa are alkaline and of 
a faintly sweetish odor, never putrid. Later on they become more 
purulent, somewhat nummular, reddish-yellow, and contain less blood. 
If there is a favorable termination, they become more fluid and frothy, 
with less blood and pus, and, on standing, show the three layers. 
The quantity varies from 25 c.c. to 500 c.c. in twenty-four hours. 
Under the microscope will be found, beside the amoeba, red blood - 
corpuscles, leucocytes, alveolar and oval epithelium, and bodies look- 
ing like degenerated liver-cells without a nucleus ; occasionally elastic 
fibres, hsematoidin, leucin, tyrosin, and Charcot-Leyden crystals and 
bacteria are seen. The cheesy particles are made up of amorphous 
granular matter and oil-globules. Amoebae are constantly present in 
varying numbers, usually not so many as in the stool, but somewhat 
larger. The number varies from day to day, and diminishes with the 
disappearance of the cough and expectoration. The sputa should be 
examined as soon after their discharge as possible, and in the interim 
should be kept at a temperature of 30° to 35° C. If examined on a 
warm stage, active movements of the amoeba? will be kept up much longer. 

They should be examined under various powers : J, -1 or l ( , and y 1 ^- 
inch objectives. Of these the 1- or T inch will be found most suitable 
for following the movements. They measure from 10// to 20 jul. They 
will be readily recognized by their size, formation, and movements. 
That they have important clinical value is true, as cases have been 
reported in which the observer diagnosticated hepatic or hepato-pul- 
monary abscess secondary to amoebic dysentery, by the peculiar anchovy- 
sauce expectoration and subsequent detection of the amoebae. 

B. Vegetable Parasites. Fungi — Non-pathogenic : Moulds. 
O'idium albicans may be a constituent of the sputum when the bronchi 
are invaded by it, but usually it is from the saliva. Certain other 
moulds have lately been considered to cause disease of the lungs by 
multiplication, but nothing very definite has resulted from the experi- 
ments thus far made. 

Yeast-fungi. Von Jaksch reports having seen scattered yeast- 
cells in the pus from a phthisical cavity. Otherwise we have no 
knowledge of yeast being found in sputa. 

Fission-fungi. Leptothrix. Leptothrix occurs alone, in the 
sputum or in the bronchial plugs, in putrid bronchitis, along with the 
fatty acid and haematoidin crystals. It is probably derived from the 
mouth, having thence entered the air-passages, or it is taken up from 
the mouth by the expectoration. It is recognized by its staining blue 
with iodine and potassium iodide. 

Sarcin^e Pulmonalis. Sarcinae may be seen in sputa. They are 
larger than sarcinse ventriculi, with which they have no connection, 
nor have they pathological significance when present in sputa. 

34 



530 SPECIAL DIAGNOSIS. 

Non-pathogenic bacilli and cocci may occur in all sputa, but are 
without significance. They are more numerous in fetid sputa. They 
stain with methylene-blue and other simple dyes. 

Pathogenic Fungi. Tubercle Bacillus. The organism which 
is the cause of tuberculosis is a rod, straight or slightly curved, without 
motion, varying in length from 2 t u to o/ul (about J to J the diameter of 
a red corpuscle). It usually has a beaded appearance when stained, 
due to the spores, which do not take up the stain that affects the rod 
as a whole, and which often bulge slightly beyond the edge. It is 
probable that this beaded appearance is caused by the contraction and 
breaking up of the stainable portion, permitting us to see the empty 
spaces between the fragments and the other membrane. Bacilli pre- 
senting this appearance are supposed to be undergoing degeneration. 
Attention has recently been called to the presence in the sputum of 
branching forms of the tubercle bacillus. The bacillus of tuberculosis 
cannot be recognized in the sputum unless stained, and in the staining 
it shows a peculiarity which belongs to but few organisms — the smegma 
bacillus, the bacillus of leprosy, and the bacillus of syphilis. As under 
ordinary conditions these bacilli are not met with, this peculiarity in 
staining in a vast majority of cases is diagnostic of tubercle bacilli. 

Recently, Pappenheim found in the sputum from a case of gangrene 
of the lung stained by Gabbet's method numerous bacilli which were 
considered to be tubercle bacilli. At the autopsy no evidence of tuber- 
culosis could be found. Further examination led Pappenheim to 
believe that these bacilli were smegma bacilli. A similar case has 
been recently seen where large numbers of bacilli were present in the 
sputum in a case of gangrene of the lung secondary to a sub-dia- 
phragmatic abscess, which, stained by Gabbet's method, were consid- 
ered to be tubercle bacilli. The autopsy showed no evidence of tuber- 
culosis, macroscopically or microscopically. Inoculation from the 
lung into a guinea-pig was also negative. Fraenkel has observed 
similar bacilli in the sputum when stained by Gabbers method from 
patients with bronchiectasis. 

Preparation of Sputum and Method of Staining Tubercle 
Bacilli. A small amount of the purulent portion of the sputum is 
spread in a thin and uniform layer on a perfectly clear cover-glass by 
means of forceps, needles, or the "oese," which must previously be 
held a moment in the flame of a Bunsen burner or spirit lamp ; or 
by pressing a small amount of sputum between two cover-glasses, 
then sliding them apart. It is then dried in the air, or more quickly 
by holding the cover-glass with forceps some distance above the flame 
of a burner or lamp. Finally, it is to be passed three or four times 
through the flame and so " fixed." The edge of the cover-glass, with 
sputum side up, is then grasped with forceps and covered with the 
staining solution, care being taken to prevent the fluid from extending 
to the under surface, and held in or just above the flame, until the 
solution boils for a second or two or a bubble rises. When the excess 
of the solution is washed off in water, the slip is treated with the 
decolorizing agent until the color is almost or wholly removed. It is 
again washed in water to remove the excess of the decolorizer, and 



PLATE XV 



FIG. 1. 









Pneumococci from a Case of Empyema. 

(Oc. 4, ob. ^f immersion.) Drawn by J. D. Z. Chase. 
FIG. 2. 



A 



/ 



\ 



f 



^ ^ 



i\~ 



.*# 



,1 ~^ iSfe 



# 



& 



Tubercle-bacilli (red). Streptococci (blue chains). 



(Oc. 4. j>2 oil immersion.) Drawn by J. I). Z. Chase. 






DISEASES OF THE LUNGS AND PLEURA. 531 

mounted for examination, or given a contrast-stain ; the latter is pref- 
erable. 

A second rapid method is as follows : Select with the sterilized 
oese a suspicious yellowish particle from the sputum ; smear it thinly 
over one end of a slide which has previously been passed several times 
through the flame of an alcohol lamp or Bu risen burner. Dry by 
holding over flame ; fix by passing several times through the flame. 
Cover the dried sputum with the desired stain, and steam gently for 
two minutes over the alcohol or low Bunsen flame ; the slide can be 
held in the fingers, or, after heating, can be laid aside for a moment ; 
wash off the excess of stain with water, then cover the stained sputum 
with decolorizing agent and counter-stain, which should not remain 
more than thirty seconds. Wash away excess with water, dry the 
slide by blowing upon it through a pipette, and cover with a clear cover- 
glass, using distilled water as a mount. This method is extremely 
satisfactory for ordinary clinical work, especially with Ziehl's and 
Gabbet's solution. 

If fuchsin has been used to stain the tubercle bacilli, methylene- 
blue is a good contrast-stain ; while if gentian-violet was selected 
Bismarck-brown is better in contrast. These contrast-stains are made 
as needed by dissolving enough of the dye in a few c.c. of water to 
make the solution as seen through a test-tube of 14 mm. diameter only 
transparent, and then filtering ; or, a concentrated watery solution 
may be made for stock just as the concentrated alcoholic solutions of 
fuchsin and gentian-violet were made, diluting a small quantity of 
this when needed with enough distilled water to make it just trans- 
parent in a similar test-tube. To apply the contrast-stain, place a few 
drops on the cover-glass that has been prepared as above — stained, 
decolorized, and washed — allow it to remain thirty or forty seconds, 
wash off in water, and mount for examination on a glass slip, in water, 
oil of cloves, or Canada balsam. A drop of water will serve perfectly 
well for examining when the preparation is not to be preserved. In 
the microscopical examinations a y 1 ^ inch oil-immersion lens and Abbe 
condenser, or, at the least, a \ or J inch objective is used. If gentian- 
violet has been used, the tubercle bacilli appear as dark-blue rods, with 
all other bodies brown, if Bismarck-brown is used for contrast-stain 
while with fuchsin staining for tubercle bacilli, and methylene-blue as 
a contrast, the former will be found as red rods in a blue field (back- 
ground). (See Plate XV., Fig. 2.) 

The above rapid method of staining takes much less time than the 
method usually described, and gives most satisfactory results. The 
steps in the old method are the same as given above, except that 
instead of placing the staining solution on the smeared and dried cover- 
glass, and holding it in or above the flame until the solution boils, the 
cover-glass is floated in a cold solution, in a watch-glass, sputum side 
down, for twenty-four hours, or in a hot solution for six to eight min- 
utes, or until moisture appears on the upper surface of the cover-glass. 
The remaining steps are similar. 

Tubercle bacilli do not stain with the simpler dyes, but when stained 
by .solutions of dyes made more penetrating by the addition of aniline 



532 SPECIAL DIAGNOSIS. 

oil, carbolic acid, or like substances, they retain the color when subjected 
to decolorizing agents. In this they differ from all other organisms, 
except, as stated, the smegma bacillus, the bacillus of leprosy, and the 
bacillus of syphilis. 

The Smegma Bacilli. Pappenheim distinguishes them from tubercle 
bacilli by staining with a solution of corallin in absolute alcohol satu- 
rated with methylene-blue, when decolorization takes place without acid. 
If fat acids and myaline are present in the sputa, the bacilli are, in all 
probability, not tuberculous. They are not found in mucopurulent, 
but in putrid, sputum. 

HouselPs method of staining them is the best. After the preparations 
are stained in carbol-f uchsin they are placed in a mixture of 3 per cent. 
HC1 in absolute alcohol for ten minutes. They stain best with an 
alcohol solution of methylal-blue, which decolorizes the micro-organism. 

A number of methods have been devised for the detection of the 
tubercle bacillus by means of its peculiar action toward stains. The 
most satisfactory are those known as the Koch-Ehrlich, Ziehl-Neelson, 
Gabbet, and Gibbes. These methods differ chiefly in the solutions used. 
Slightly modified from the original in execution, they are as follows : 

A. Koch-Ehrlich method : 

Solutions Used. 

I. Concentrated alcoholic solution of fuchsin or gentian-violet. 
II. Saturated solution of aniline oil in water. 
III. Thirty per cent, solution of nitric acid in water (decolorizing solution). 

I. Place in a clear bottle fuchsin or gentian-violet in substance to 
one-fourth its capacity, and fill with alcohol (95 per cent.) ; shake well 
and cork and allow it to stand for twenty-four hours. If all the dye has 
been dissolved, add more and shake, and let stand for another twenty- 
four hours, and so on until some of the dye remains permanently 
undissolved at the bottom of the bottle. This solution remains good 
until used. 

II. To about 100 c.c. of distilled water, in a flask or other suitable 
vessel, add aniline oil, drop by drop, shaking the flask continuously, 
until the solution is opaque, or drops of the oil float on the surface, 
then filter through moist filter-paper until the filtrate is perfectly 
clear. This solution must be made fresh as needed. 

III. Mix a few c.c. of nitric acid and water in about the above pro- 
portion, never stronger, each time bacilli are to be stained. 

The Koch-Ehrlich solution is made by adding 11 c.c. of the fuchsin 
or gentian solution (No. I.), and 10 c.c. of absolute alcohol to 100 c.c. 
of the clear aniline nitrate (No. II.). It should not be used after it is 
a week old. 

B. Ziehl-Neelson method : 

Solutions Used. 

I. Carbolic-fuchsin solution : 

Distilled water . . . . . 100 c.c 
Carbolic acid (crystalline) .... 5 grammes. 

Alcohol 10 c.c. 

Fuchsin in substance ..... 1 gramme. 



DISEASES OF THE LUNGS AND PLEURJE. 533 

This solution can also be prepared by adding saturated alcoholic 
solution of fuchsin (see above) to a 5 per cent, watery solution of car- 
bolic acid, until a metallic lustre is seen on the surface of the fluid. 
This solution does not decompose so easily as those made with aniline 
oil. 

II. Decolorizing solution of nitric acid, and 
III. Contrast stain of methylene-blue, as above. 

The preparation and staining are exactly the same as in method A. 
The tubercle bacilli are stained red, the other bodies blue. 

C. Gabbet's method : 

Solutions Used. 

I. Carbolic-fuchsin solution (as in B). 
II. Methylene-blue solution : 

Methylene blue 1 2 grammes. 

Sulphuric acid 25 " 

Distilled water . . . . . . 75 c.c. 

This solution is apt to decompose if old. 

Preparation of Slips and Staining. The cover-glass is pre- 
pared and stained with the carbolic-fuchsin solution and washed in 
water as in A. Then (instead of decolorizing with nitric acid or add- 
ing in contrast-stain) the slip is washed for twenty to thirty seconds in 
the methylene-blue solution, until a faint blue replaces the red tinge 
in the (slip) sputum ; the excess of the solution is washed off in water, 
and the slip is mounted and examined as above. The tubercle bacilli 
are stained red and the other bodies blue. In sputum from gangrene 
of the lung and bronchiectasis, decolorization with alcohol, in addition, 
must be employed to eliminate the presence of the smegma bacillus. 

The writer has found that this method can be rapidly applied, and 
that it gives good results ; he recommends it highly. 

D. Gibbes' method : 

Solutions Used. 

I. a. Fuchsin ........ 3 grammes. 

Methylene-blue 1 " 

Mix thoroughly in a mortar. 
b. Aniline oil . . . . . . 5 c.c. 

Alcohol 20 c.c. 

Dissolve and add b to a slowly, stirring vigorously until a is evi- 
dently dissolved, then add 20 c.c. of distilled water, and keep in a 
stoppered bottle, ready for use. 

Prepare slip and stain with this solution, as with the others, up to 
the point of decolorizing. Then wash with alcohol until the dye ceases 
to come away. Mount and examine as above. Tubercle bacilli will 
be stained dark red, the other objects dark blue. 

When the bacilli are few in number, Biedert proposes that the fol- 
lowing preliminary steps be taken : About -4 c.c. of sputum are mixed 
with 8 c.c. of Avater and 1 c.c. of solution of caustic soda, and boiled a 

1 An alcoholic solution of methyl-blue should first be made, and then added, drop 
by drop, with constant stirring, to the sulphuric acid and water. 



534 SPECIAL DIAGNOSIS. 

few minutes, when about 15 c.c. of water are added and the whole 
again boiled until a homogeneous fluid is formed. This is allowed to 
stand in a conical glass for twenty-four to forty-eight hours, when the 
sediment is stained by the Ziehl-Neelson or Gabbet method. Or, the 
homogeneous fluid can be put at once in a centrifugal machine, and the 
resulting sediment stained. 

Sputa hardened in Zenker's fluid, embedded in paraffin and cut, has 
proven most satisfactory in the study of the branching forms of the 
tubercle bacillus, the study of giant-cells in the sputum in phthisis, 
and in the study of bacteria in the sputum in cases of pneumonia. 

It is well to remember that, in the absence of a proper decolorizing 
agent, hot water applied for some minutes has been shown to decolor- 
ize very satisfactorily. 

Importance. The greatest importance attaches to the presence or 
continuance of tubercle bacilli in sputa. It indicates tuberculosis of 
the lung or larynx ; in the vast majority of cases of the former. 

They are often to be found in the sputum when physical signs are 
not yet present or are indefinite. The number varies so greatly in 
different cases, and in the same case at different times, that a in recent 
attack it is impossible to judge of the extent of the disease by the 
number present in a given preparation. 1 

The absence of bacilli from sputa has no true value unless negative 
results are obtained after many trials and careful examination by an 
experienced observer, using good stains. Hence, too great care cannot 
be taken in each and every step. 

Biological Properties. The tubercle bacillus is difficult to cul- 
tivate, as it grows readily only in conditions found within the body. 
The best medium is blood-serum. The cheesy mass from the sputum 
or the tubercular nodule from a tissue is placed on the surface of the 
serum and rubbed carefully over it. It is best to make twenty or 
thirty such inoculations. The tubes must then be sealed to prevent 
evaporation and drying, and exposed for twelve days to a temperature 
of 37.5° C. When a pure culture is obtained further cultivations may 
be made on agar-agar, to which 6 per cent, of glycerin has been added. 

The pure cultures appear as dry masses on the surface of the medium, 
either as flat scales or clumps of mealy-looking granules. They are 
of a dirty drab or brownish-gray color. (See Plate VII., Fig. 6.) The 
bacillus is parasitic, aerobic, non-motile (facultative anaerobic). 

Pneumococcus. Diplococcus Pneumoniae. Micrococcus Lan- 
ceolatus. The causative factor in most cases of acute croupous pneu- 
monia in its typical form is a paired lancet-shaped coccus, often irreg- 
ular in size, with a tendency to chain formation. Frequently oval or 
conical forms are present, and there is apt to be variation in the size 
of the two cocci forming the pair. The organism has a distinct cap- 
sule. In the sputum of croupous pneumonia these pneumococci are 
usually present in large numbers. Their presence within leucocytes 

1 " A Method for the Examination of the Actual Number of Tubercle Bacilli in 
Tuberculous Sputum." By George H. F. Nuttall, M.D., Ph.D., Johns Hopkins 
Hospital Bulletin, May, 1891. The method is of pathological but not of diagnostic 
interest. 



DISEASES OF THE LUNGS AND PLEURA. 535 

and their tendency to chain formation has been especially noted in 
such cases. 

Pneumococci are stained in cover-glass preparations with the ordi- 
nary aniline dyes, as given above. The capsule may be stained and 
differentiated in the same way, but it more often requires a special 
method. Welch recommends the following : Spread and dried cover- 
glass preparations are treated first with glacial acetic acid, which is 
allowed to drain off, and is replaced (without washing in water) with 
aniline oil-gentian-violet solution. (See under Tubercle Bacilli.) The 
staining solution is repeatedly added to the surface of the cover-glass 
until all of the acid is displaced. The specimen is now washed in a 
weak salt solution (about 2 per cent.), and examined in the same, not 
in balsam. The capsule and coccus can then be differentiated. Spu- 
tum stained by Gram's method, thoroughly decolorized by alcohol, 
counter-stained with a watery solution of eosine, or a 1 per cent, aque- 
ous solution of aurantia, has been found satisfactory for microphoto- 
graphic work. Degenerative and involution forms are constantly met 
with. There will be variations in size and shape, and the capsule may 
contain onlv remains of a coccus, or be entirelv empty. (See Plate 
XV.) 

Biological Properties. The pnenmococcus is not motile. It 
stains by Gram. It grows well on blood-serum. The growth is 
minute, transparent, colorless colonies, resembling drops of dew. A 
favorable growth of very minute colonies appears in glycerin agar- 
ao;ar. Bouillon is faintlv clouded. Litmus milk will sometimes 
turn pink and coagulate. Growth on other culture media is usually 
feeble. The tendency to form chains is especially observed in the 
water of condensation on blood-serum tubes. The lancet shape of 
the cocci enables them to be differentiated from the streptococcus. 
The capsules are not usually observed in the cultures with ordinary 
methods of staining. 

By inoculation into susceptible animals a typical fibrinous pneumo- 
nia is developed. The pathogenic power attenuates rapidly in cul- 
tures, but recovers its virulence by passing through susceptible animals. 

This micro-organism is found in nearly all cases of acute croupous 
pneumonia, and in many cases of bronchopneumonia. Its presence 
has also been observed in health in the saliva. It is found also in 
acute pleuritis, endocarditis, pericarditis, peritonitis, acute purulent 
meningitis, and otitis media. Its presence in empyema is considered 
of favorable import. It has also been found in cases of synovitis, 
osteomyelitis, and abscess formation in various situations. It may 
cause a general septicaemia — i. e., pneumococcus septicemia. 

Bacillus Mucous Capsulatus. This organism is found in the 
sputum in health in a certain number of cases. In association with 
the pneumococcus it can cause pneumonia. It can also produce pneu- 
monia by itself in rare instances. 

In three fatal cases of pneumonia due to the capsule bacillus alone, 
there have been found in the sputa large numbers of capsule bacilli. 
These were frequently inside of leucocytes, and many alveolar cells 
were filled with these bacilli. 



536 SPECIAL DIAGNOSIS. 

Bacillus of Influenza. This organism is found in the sputum 
in cases of influenza or influenza pneumonia. It was first isolated 
from the sputum by Pfeiffer. The organism appears as a small 
bacillus with rounded ends. Its length varies somewhat, and thread- 
like, involution forms may appear. It stains more deeply at the ends 
than at the middle, and the long forms may show irregularity of stain- 
ing. It does not grow on the ordinary media. It is best cultivated 
upon agar-agar slants, upon the surface of which . has been smeared a 
few drops of blood. The colonies appear after twenty-four to thirty- 
six hours as minute, colorless, watery, clear, dew-like colonies, best 
seen with a hand lens. In the sputum these bacilli are frequently 
present in large numbers in cases of influenza, and their presence fill- 
ing up the protoplasm of the leucocytes and the purulent sputum of 
pneumonia is not uncommon. Thin smears of the sputum, stained 
with aniline oil-gentian-violet, somewhat decolorized with alcohol, and 
counter-stained with a 1 per cent, aqueous solution of aurantia, have 
shown these bacilli much better than the ordinary methods of staining 
with Loffler's methylene-blue or dilute carbol-fuchsin. 

Whooping-cough. Minute bacilli have been discovered in the 
sputum in cases of whooping-cough by Czplewski, Koplik, Zusch, and 
others. At present the results are not sufficiently uniform to prove 
these bacilli of etiological value in the disease. 

Actinomyces. When the lungs or pleura are infected by this 
fungus actinomyces may be found in the sputum. The disease in 
these organs is rare. Macroscopically they appear as small kernels, 
yellowish-white or greenish-yellow, and having the shape of a millet- 
seed. Under the microscope they are recognized by the rounded, 
club-like bodies projecting from all sides of an unformed central mass. 
They are seen better when not stained. (See page 352.) 

Chemistry of Sputum. As the chemical examination of the 
sputum does not aid us in diagnosis, it has but little or no value. 
Mucin, nuclein, and serum albumin are constituents of sputa in health. 
Peptone is present whenever there is pus, and is especially marked in 
pneumonia. Volatile fatty acids, such as butyric and acetic, occur at 
times, markedly so in pulmonary gangrene. Glycogen has been 
obtained by Solomon, and a ferment resembling one of the pancreatic 
ferments has been detected, especially in pulmonary gangrene and 
putrid bronchitis. Of inorganic substances, chlorides of soda and 
magnesia ; phosphates of soda, lime, and magnesia ; sulphates of soda 
and lime ; carbonate of soda, lime, and magnesia ; and in a few cases 
phosphate of iron and silicates have been obtained (Von Jaksch). 

SPECIAL DIAGNOSIS. 

Pictoric Records of Physical Signs. 

In order to draw accurate conclusions from the various data obtained during 
the physical examination of a patient, the physician must carry in his mind the 
results of the inspection, the palpation and percussion, and the auscultation of 
each individual part of the thorax and abdomen. For the beginner the grouping 



PLATE XVI 



■ 



FIG. 1. — Anterior Aspect. 



I M 





1 

1 








a 


/* 


1 


W Wm 


1 

EC 


3^ 






& 


d , 


■C/ A 



S^-P 




?' 








i -fFM 

Nil 
1 
























FIG. 2. — Posterior Aspect. 




Physical Signs in Health. 

Normal percussion outlines of the viscera. Normal heart and breath sounds 
Vertical lines for localization. 






DISEASES OF THE LUNGS AND PLEURJE. 537 

together of these phenomena according to regions of the body, instead of by 
methods of examination, is extremely difficult. He is taught to examine the 
thorax, first, by inspection, then by palpation and percussion, and, finally, by 
auscultation ; and in following this routine the results of the examination 
naturally divide themselves into the signs obtained by this method or that. In 
making the diagnosis, however, the grouping must be rearranged, for in order to 
determine the condition of a certain organ or part of an organ, all the local 
phenomena, by whatever method recognized, must be considered in their rela- 
tion to one another and not merely as isolated facts. By weighing all the 
evidence obtained by the various methods of examination, and by balancing the 
relative importance of this sign or that, a verdict is finally reached in regard to 
the condition of the part in question. Only after the status of each organ has 
been thus separately determined can a complete diagnosis of the case be made 
with certainty. 

In describing in the text the physical signs of the various diseases of the 
internal organs, it is necessary, in order to avoid endless confusion, to consider 
data in the order in which they are elicited — i. e., grouped according to the 
method of their recognition. To redescribe them grouped according to regions 
would involve constant repetition, and would still fail to give a clear picture of 
the sign-complex of the part. And yet it is essential that this picture should be 
so clear and well defined that the physician, in summing up the examination, 
has but to glance at the part in order to call up to his mind all the various data 
obtained by its examination. Experience adds daily to the facility with which 
this piece of mental gymnastics is performed, and it finally becomes half-auto- 
matic, but for the beginner it is most discouragingly difficult. He may, how- 
ever, obtain great assistance in acquiring the right habit of thought by system- 
atically writing down each sign as it is perceived, and by grouping with it the 
other signs belonging to the same region. This he may do by means of short 
descriptions, or, better still, he may employ symbols to represent the various 
sounds, etc., and may mark them directly on the patient's body, or may fill them 
in on blank diagrams of the thorax and abdomen, and thus obtain a complete 
and vivid picture of the results of the examination of each separate region 
The practical value of this method, both as an aid to the beginner and as an 
easy and accurate means for preserving records, has been widely recognized, 
and numerous symbols have been devised, to represent graphically the various 
physical signs. Those suggested by Wyllie, of Edinburgh, and by Sahli, of 
Bern, are among the best. Many of the symbols used in the following plates 
will be recognized as borrowed from the above authors. 



Explanation of the Symbols Used in the Plates Illustrating Special 

Diseases. 

Percussion Sounds. Superficial dulness (also called absolute dulness) is 
alone indicated in the following plates. As has already been stated, the per- 
sonal equation enters so largely into the determination of the extent of deep 
(relative) dulness that it is scarcely possible to make any positive statements in 
regard to the areas over which it is obtained in health and in disease. Absolute 
dulness is, on the other hand, easily recognized, and it is, therefore, far better 
that the student first become thoroughly familiar with this, about which there 
can be little or no question, before being taught what, in the case of relative 
dulness, is after all merely the expression of the individual skill and acuteness 



538 SPECIAL DIAGNOSIS. 

of ear of the instructor. With a clear picture of the areas of superficial dulness 
once firmly fixed in the mind, the student should for himself determine just how 
far he individually is able to rely upon his perception of deep dulness. As his 
skill in percussion increases, and as his ear becomes better trained, he will find 
himself progressively better able to make use of deep dulness as an aid in diag- 
nosis. He should, however, remember that many skilled diagnosticians are 
content to rely almost exclusively upon superficial dulness. 

Blue shading = Areas of superficial dulness ; the intensity of the color ex- 
presses the intensity of the dulness. 

HR = Hyper-resonance. 

T = Tympany ; the pitch is indicated by a dot above or below 

the letter. 

Breath- sounds. An ascending line indicates inspiration ; a descending line 
expiration. The length of the line shows the length of the sound, the thickness, 
its intensity. A dot above or below the line indicates high or low pitch. Two 
cross lines are used to designate bronchial breathing ; a single cross line indi- 
cates broncho vesicular breathing. An interrupted line stands for cog-wheel or 
interrupted breath-sounds. 

/\ = Normal vesicular breath-sounds. 

/\ = Weak vesicular breath-sounds. 

S\ = Harsh vesicular breath-sounds (puerile breathing). 

>/\ = Harsh vesicular inspiration, prolonged vesicular expiration. 

jJ"\ = Sharp vesicular inspiration, slightly prolonged vesicular expi- 

ration. 

/\ = Interrupted (cog-wheel) breath -sounds. 

= Bronchial breath-sounds (bronchial breathing), inspiratory 
and expiratory. 

= Bronchovesicular inspiration, low-pitched bronchial expira- 
tion. 






Rales. Dry rales are represented by undulating lines, the length corresponding 
to the duration, while a dot above or below the line indicates the pitch. 

^v^v^a = Sonorous rales. 

^w = Sibilant rales. 

Moist rales are represented by circles the diameter of which indicates the size 
of the rales. An ascending line drawn through the circle shows that the rale is 
heard during inspiration, a descending line that it is heard during expiration. 
The clear, sharp, moist rales heard over consolidated areas, rales with over-tones, 
are indicated by large or small dots, according to their size. 
? = Small, moist (subcrepitant) rales. 

° ° = Medium-sized moist rales. 

ft ^ = Large moist rales heard during both inspiration and expira- 

tion. 

o = Lan>e and small moist rales. 

O & 






DISEASES OF THE LUNGS AND PLEURA. 539 

= Small moist rales heard over consolidated areas. 

= Medium-sized moist rales heard over consolidated areas. 

= Large moist rales heard over consolidated areas 

^•^ = Large and small moist rales heard over consolidated areas, 

• . 

Crepitation. 

rC'A, == Crepitant rales,, to be heard only during inspiration. 

Friction Rub. 

AV\Aaa = Friction rub, as heard over any serous surface. 

Heart-sounds. The symbols used to indicate the feet in Latin poetry are 
made to represent the heart-sounds. The straight line indicates the longer, the 
curved line the shorter sound. The thickness of the lines shows the relative as 
well as the absolute loudness. 

— u = Normal heart-sounds as heard over the mitral and tricuspid 

regions. 
u — = Normal heart-sounds as heard over the aortic and pulmonic 

regions. 
^ — = Normal first sound, accentuated second. 

— ww = Loud first sound, reduplicated second. 

~ — = Loud first and second sounds of equal intensity. 

Murmurs. Murmurs are represented by short parallel lines either increasing 
or diminishing in length, according as the murmur increases or diminishes in 
intensity. The thickness of the lines shows the loudness of the murmur, the 
number of lines shows its duration. 

Illllin. = A soft murmur, commencing distinctly and gradually fading 

away. 

Ilfllin. = A loud murmur of the same character. 

■ill = A short loud murmur, increasing in intensity (type of pre- 

systolic murmur). 
= Loud first sound, slightly accentuated second sound; short 
loud presystolic murmur, increasing in intensity to end with 
the first sound ; long, soft, systolic murmur. 

Fremitus. 

F + = Increased fremitus. 

F — = Diminished fremitus. 

NoF = Absent fremitus. 

Other Symbols. 

X = Impulse. 

M = Margin (of an organ). 

R = Eetraction. 

B = Bulging. 

v = Visible. 

p = Palpable. 

Xvp = Visible and palpable impulse. 

IV|vp = Visible and palpable margin, 



■l|l!l 



540 SPECIAL DIAGNOSIS. 

The Neuroses. 

The neuroses are affections of the lungs unattended by structural 
change. To this class belong the varieties of rapid breathing, of slow 
breathing, of cough and of dyspnoea which appear to arise without 
structural change, and which are discussed exhaustively in the section 
devoted to the subjective symptoms. Among other neuroses, asthma 
is fully treated of, and other forms of dyspnoea and cough are 
considered. Reference need not be made further to the respiratory 
neuroses other than to bear in mind that their presence may or may 
not be unattended by organic change in the lungs. On the other 
hand, we are likely to find the general phenomena or stigmata which 
are associated with neuroses of other organs, as well as the lungs. 
Hence, the condition of neurasthenia is likely to be present on the one 
hand, or the numerous stigmata of hysteria may be found on the other. 

The Congestions. 

Congestion of the Lungs. Active Congestion. In active con- 
gestion there is an increased amount of blood, which diminishes the 
air-space by encroachment and causes more or less consolidation. The 
signs of that physical condition are present — increased fremitus, im- 
paired resonance or dulness, and bronchial breathing. They are 
observed on both sides, usually at the bases. Dyspnoea, cough, and 
frothy, bloody expectoration attend the fluxion. No cases have yet 
been reported in which bacteriological examination of the sputum was 
made. Of course, the micrococcus lanceolatus is not found. 

If the above signs and symptoms develop suddenly — within twenty- 
four hours — a fluxion to the lung has in all probability taken place. 
If the patient is subject to heart disease, or if he has been exposed to 
and has inhaled hot vapors or irritants, the probability of fluxion is 
increased. The occurrence of fever Avould point to pneumonia as the 
cause of the objective and subjective symptoms. 

Passive Congestion. The physical condition that results is con- 
solidation, manifesting itself by slight dulness and feeble or bronchial 
breathing ; the bronchial mucous membrane is also congested, giving 
rise to abundant large rales. The affection is bilateral and usually 
confined to the posterior portions of the bases. It is also secondary. 
a. Mechanical congestion occurs when the flow of blood to the heart is 
obstructed, as in organic valvular disease or insufficiency. Rarely the 
pressure of tumors on the pulmonary veins acts in a similar manner. 
6. Hypostatic congestion occurs in fevers, as protracted typhoid, and 
in prolonged general exhaustion or adynamia. Ascites or other affec- 
tions below the diaphragm, which lessen the respiratory excursion, 
cause this form. Dyspnoea, cough, and expectoration of blood-stained 
sputum are common. The sputum contains alveolar cells, often pig- 
mented, but no micro-organisms. 

(Edema. The air-cells and alveolar walls are filled with serous 
exudation, as in oedema of the skin. It is frequently due to the weak- 
ness of the heart, which occurs at the end of long-continued diseases 



DISEASES OF THE LUNGS AND PLEURA. 541 

of an exhaustive nature, particulaly if the heart is overtaxed. It 
occurs, therefore, in the terminal stages of chronic Bright' s disease, of 
organic heart disease, of the anaemias and cachexias. Both congestion 
and oedema occur in cerebral affections. 

Symptoms. They are those of congestion in a more aggravated 
form. Dyspnoea, cough, and the expectoration of large quantities of 
a seromucoid fluid are seen. The diagnosis is based upon the result 
of physical examination and the history of the above causal factors. 
In cases of myocarditis or acute dilatation of the heart, in valvulitis 
with failing compensation, oedema of the lungs often takes place sud- 
denly. It may follow some unusual exertion. Its onset is attended 
with more or less collapse, increased pulse-rate, hurried, oppressed, 
noisy breathing, cyanosis, and an anxious expression. The physical signs 
are an unusual number of small rales throughout the chest, apparently 
created in the air sacs, and imperfect resonance, showing that some 
lobules are collapsed. 

Pulmonary Embolism and Thrombosis. Pulmonary embolism 
consists in plugging of the pulmonary artery or its branches by coagula 
formed in the right heart or in the veins. The symptoms depend upon 
the size of the occluded vessel and upon the nature of the embolus — i. e., 
whether septic or not. If the artery itself is plugged, death takes place 
suddenly or after a short interval, with symptoms of syncope or asphyxia. 

Symptoms. If a large branch is plugged, the first symptom is gen- 
erally intense dyspnoea, which may amount to an agonizing craving 
for air. Pain in the chest, which may or may not be acute, is com- 
plained of, and may be referred to the seat of the embolus. Cough is 
not a common symptom, and may be altogether absent. The breath 
ing is considerably altered ; it is usually increased in frequency, and 
may be much hurried ; it may or may not be shallow, and Avhile the 
patient can take a deep inspiration, it does not give relief to his dysp- 
noea. At times it is irregular and gasping. 

The face is pale or may be cyanosed, and is apt to be bathed in per- 
spiration. The veins are swollen and prominent. The heart's action 
is irregular and may be tumultuous. Exophthalmos has been ob- 
served. The temperature falls below normal, but a febrile rise may 
occur later. The intellect is unclouded. 

The physical signs are indefinite. The respiratory murmur is rough- 
ened and exaggerated in most, but not in all cases. Fox states that 
rales are very rarely heard. Collapse, oedema, and bronchitis are possi- 
ble results. A systolic blowing murmur may be heard over the heart 
and pulmonary artery, and in protracted cases albuminuria and oedema 
may be met with. 

When the embolus is septic, a septic pneumonia or metastatic abscesses 
are probable results in cases not immediately fatal. 

When the emboli produce hemorrhagic infarcts the symptoms are 
milder, and consist principally in dyspnoea, pulmonary hemorrhage, 
and palpitation. The onset is sudden and accompanied by a fall in 
temperature. The physical signs indicate consolidation, if the pneu- 
monia or infarcted area is of moderate size. It may be discovered at 
the root of the lungs in the interscapular region. 



542 SPECIAL DIAGNOSIS. 

Haemoptysis is a common symptom when the embolus has arisen in 
the heart. The amount of blood varies from a copious expectoration 
to the rusty sputum seen in pneumonia ; it may persist for weeks. 
Pleurisy and pleural effusion are frequent complications ; chills occur 
sometimes, and pneumonia, with corresponding rise of temperature, 
may develop. 

The most important points in diagnosis are the sudden onset of the 
dyspnoea and other pulmonary symptoms, and the detection of a con- 
dition which would give rise to emboli, such as puerperal fever or 
heart disease. 

The Inflammations. 

The Bronchi. Inflammations of the bronchi are distinguished from 
other diseases of the lungs chiefly by the difference in the physical 
signs. Except in capillary bronchitis, the general and subjective 
symptoms are not so severe as in other affections. 

Signs Peculiar to Inflammations of Bronchi. We are aided 
in the recognition of bronchial affections, first, by the fact that they 
are bilateral ; second, that the bases are usually affected ; third, that 
there is diminution of fremitus determined by palpation ; fourth, that 
there is absence of dulness on percussion ; fifth, that rales are more 
pronounced in proportion to other physical signs, and more general 
than in other lung affections. 

Bronchitis. Bronchitis is an inflammation of the mucous mem- 
brane of the bronchial tubes. It may be acute or chronic, may in- 
volve any part of the bronchial tree, the large, the middle-sized, or 
the most minute branches, and may be primary, or occur secondarily 
to some general disease, or to disease of the heart or kidneys. 

Acute bronchitis occurs most frequently by extension of the 
catarrhal inflammation from the nose and throat ; but in some persons 
it develops so suddenly that it appears to be primary in the tubes. 

When the larger or middle-sized tubes are involved, the patient com- 
plains of soreness or rawness underneath the sternum, especially at its 
upper part. There are frequently a feeling of tickling in the throat, 
and a sense of weight or oppression on the chest. Chest pain is due 
to myalgia or the strain upon the muscles from coughing. The cough 
is at first hard and dry, and often produces pain of a tearing character 
in the muscles of the chest and abdomen. The cough is apt to be 
A\ r orse when the patient first lies down, and again on rising, especially 
after a night's rest. Fever is usually slight and of short duration. 
The respirations are accelerated, but not markedly, and there is no 
dyspnoea. The expectoration is at first a white, frothy, viscid mucus, 
subsequently becoming more abundant and mucopurulent. 

Physical Signs. In uncomplicated cases there are no changes in the 
physical structure of the lungs. On examination of the chest the per- 
cussion-note is found to be clear ; the respiratory murmur more rough- 
ened and harsher than normal, but not broncho vesicular or bronchial ; 
accompanying breathing there are heard sibilant and sonorous rales, 
and, in the later stages, some large and medium-sized mucous rales. 
The rales vary in position from time to time, and especially after 



DISEASES OF THE LUNGS AND PLEURAE. 543 

coughing. Vocal resonance and fremitus are unaltered. A fremitus 
may be produced by sonorous rales. 

The cough and expectoration usually last for some time after fever 
has subsided. The duration of the disease is from a few days to sev- 
eral weeks. It is never fatal except in the very old and very young, 
or in those who are much debilitated. 

The diagnosis of acute bronchitis is easily made by noting the fact 
that the disease runs an acute course, marked by fever, cough, and ex- 
pectoration ; and that the physical signs are negative, except as to 
roughening of the respiratory murmur and the existence of bronchial 
rales, heard on both sides of the chest. 

From croupous pneumonia and local tuberculosis of the lungs it is 
distinguished by the absence of dulness on percussion, bronchial 
breathing, and increase of vocal resonance and fremitus ; by the 
absence, in other words, of the ordinary signs of consolidation. From 
pneumonia it is further distinguished by the milder character of the 
subjective symptoms, and by the fact that in bronchitis the physical 
signs are almost always bilateral, in pneumonia generally unilateral. 
It is further distinguished from tuberculosis by the slow progress of 
the latter, which involves the apices preferably, whereas bronchitis is 
more marked at the bases ; and by the occurrence, sooner or later, of 
hectic fever and emaciation, which are absent in bronchitis. Doubt 
will exist only at first ; the progress of the case will in time make 
everything clear. Systematic examination of the sputum is an impor- 
tant diagnostic aid, and will lead to the differentiation of many cases 
of bronchitis from tuberculosis and from pneumonia. In infants and 
children especially, bronchitis is at times so rebellious to treatment 
that tuberculosis is suspected. 

In bronchopneumonia (catarrhal pneumonia) there is a diffuse bron- 
chitis associated with small areas of pneumonic consolidation. It is 
distinguished by having graver general symptoms and by the presence 
of small areas over which there are dulness on percussion and bronchial 
breathing, associated with physical signs of bronchitis already de- 
scribed. 

Acute miliary tuberculosis of the lungs is very easily mistaken for 
bronchitis, because dulness, if present, amounts to nothing more than 
tympanitic dulness, because the signs are diffused through both lungs, 
and because the respiratory murmur is fainter than normal, but only 
slightly roughened. Close inspection of the patient will, however, 
make it evident that his condition is worse than could be accounted 
for by bronchitis alone. The fever is higher, the respirations more 
frequent, pallor, with a dusky or faintly cyanotic hue intermingled, is 
common, perspiration is more pronounced. A primary focus or a 
source of infection may be discovered. 

Acute bronchitis may be mistaken for spasmodic laryngitis (croup). 
It is distinguished by the fact that the spasms are less pronounced in 
bronchitis, and there is fever in addition to the physical signs. In 
bronchitis the breathing is rarely so stridulous as in laryngeal spasm. 

Whooping-cough cannot be distinguished positively from bronchitis 
before the characteristic whoop appears ; but it may be suspected when 



544 SPECIAL DIAGNOSIS. 

the child has been exposed to contagion, and when the coryza and 
redness of the fauces persist in spite of treatment. 

In the diagnosis of bronchitis it is more often difficult to determine 
the primary cause than it is to distinguish it from other pulmonary 
affections. Yet the former is more important ; it must be borne in 
mind that bronchitis is a frequent accompaniment of many febrile dis- 
eases, such as typhoid fever, measles, and whooping-cough ; of diseases 
of the heart and kidneys, and of septic diseases and blood disorders. 
The primary will not be likely to be mistaken for the seconday dis- 
order if one is upon his guard and insists upon finding a cause for each 
case that presents itself. 

Measles can usually be diagnosticated from the first by the coryza, 
but especially by the red spots upon the anterior half-arches of the 
soft palate, which appear usually several days before the eruption upon 
the body. 

Bronchitis is a common and important early symptom of typhoid 
fever. The latter disease may be suspected when the fever, prostra- 
tion, and headache are greater, and, especially if these symptoms coex- 
ist with a loose condition of the bowels, chilliness, and occasional nose- 
bleed. 

Chronic bronchitis occurs most frequently in middle or later 
life. Its special feature is long duration, without fever, and with 
comparatively little impairment of the general health. Cough is not 
constant ; there are periods when it is entirely absent ; the disease 
then returns, perhaps with increased severity, and lingers indefinitely. 

Chronic bronchitis in its milder form consists in what is often 
called " winter cough." It attacks especially persons past middle life 
who have emphysema. It appears with the cold weather, and lasts 
until the following summer. The cough is not severe, though some- 
times paroxysmal, and expectoration is scanty, non-purulent, and may 
be confined to the morning. Dyspnoea is not marked unless there is 
considerable emphysema. Acute exacerbations occur from time to 
time, and the tendency of the disease is to become worse from year 
to year, and to be more continuous, even persisting all summer. 

In the dry catarrh, or catarrhe sec of Lsennec, paroxysms of cough 
occur on the slightest provocation, with the expectoration of small, 
hard pellets, or without any expectoration. The patients are emphy- 
sematous. 

The diagnosis is made by noting the long duration of the disease 
without impairment of the general health, its relation to season, and 
the absence of physical signs of involvement of lung tissue. 

The physical signs of chronic broncriitis are those of bronchitis of 
the larger and middle-sized tubes. Large moist rales are more or less 
abundant, depending upon the degree of swelling of the mucous mem- 
brane, and the quantity and fluidity of the secretions. The respiratory 
murmur is roughened and less intense than normal. 

\\ r . Fox says that in chronic bronchitis there is commonly hyper- 
resonance from coexisting emphysema, but under acute exacerbations 
the bases may be dull from congestion or oedema. Respiration is 
harsh, and in some cases of senile bronchitis expiration may be both 



DISEASES OF THE LUNGS AND PLEURAE. 545 

prolonged and high pitched, when other signs of dilatation of bronchial 
tubes are absent. The percussion-note is clear. 

The sputa of the severe forms of chronic bronchitis are usually 
copious and mucopurulent, the latter predominating. They vary in 
color from yellowish-white to ashy, greenish, or black when the lungs 
are anthracotic or collapsed. 

The subjective symptoms of the patient consist, in ordinary cases, of 
a moderate amount of dyspnoea, and tightness across the chest. At 
the onset of a fresh attack the symptoms may be those of acute bron- 
chitis. The cough is paroxysmal, somewhat resembling that of whoop- 
ing-cough, but without the characteristic whoop. It is usually severest 
on lying down and when rising in the morning. 

The quantity and character of the sputa vary more than in acute 
bronchitis. Sometimes they are very copious, consisting of serum 
mixed with mucus, constituting bronchorrhoea. More commonly they 
are scanty, glairy, and tenacious. 

Chronic bronchitis may be the result of repeated acute attacks, or, 
rarely, of only one. It is frequently found in association with gout, 
chronic heart disease, chronic endarteritis, Bright' s disease, emphy- 
sema, asthma, and chronic alcoholism. It may alternate with other 
gouty affections, as articular inflammation or eczema, being relieved 
when the other manifestations are more marked. It also accompanies 
tuberculosis of the lungs. Climate and season have a marked influ- 
ence ; the disease is worse in damp, cold climates, and in the' winter 
months. 

Chronic bronchitis can be diagnosticated from the cough of aneurism 
by the absence of the stridulous breathing, due to paralysis of one-half 
of the vocal cords, and by the local signs of a tumor of the vessel. 
Other tumors may cause cough by pressure, and the possibility of their 
existence should, therefore, be borne in mind. 

Capillary Bronchitis, or Suffocative Catarrh, is bron- 
chitis of the smaller tubes. It occurs most frequently as an extension 
of the catarrhal process from the larger tubes, but sometimes seems to 
attack the smaller tubes from the beginning, or coincidently with the 
larger tubes. Infants, young children, and the aged are most liable to 
it. It begins with a succession of chills or chilliness, followed by high 
fever. The temperature may rise to 104°. The skin is hot, the face 
flushed. The head and neck and the upper portion of the trunk may 
be covered with perspiration. The pulse rapidly increases in frequency. 

The aspect of the patient from the first shows that the illness is 
graver than ordinary bronchitis. The face expresses anxiety, and in 
children the alse nasi dilate in respiration, which is both accelerated 
and difficult (dyspnoea). The respirations may be as many as 60 or 
80 to the minute, the pulse not being correspondingly rapid. Dysp- 
noea is more or less constant, but becomes urgent in paroxysms, and 
the patient may have to be propped up in bed to enable him to breathe 
(orthopnoea). It is expiratory: inspiration may be free and easy, or 
difficult ; but expiration is always difficult and prolonged. In children 
the pause in the act of breathing takes place at the end of inspiration, 
instead of expiration. 

35 



546 SPECIAL DIAGNOSIS. 

Cough is more frequent and violent than in ordinary bronchitis, and 
the expectoration is viscid and difficult to raise. As the disease pro- 
gresses, dyspnoea becomes more intense, and signs of insufficient aera- 
tion of the blood make their appearance (cyanosis). The lips and 
finger-nails become bluish, and the extremities cool and clammy. If 
the patient is unable to expel the tenacious secretions from his bron- 
chial tubes, the further progress of the case is that of rapidly develop- 
ing cyanosis ; the breathing continues frequent, but is shallow and 
more labored. Children often have convulsions, followed by coma and 
death, while old persons sink into coma without preceding convulsions. 

The physical signs (Plate XVII.) are those of bronchitis of the larger 
and smaller tubes ; sibilant and sonorous rales, if present at first, give 
way to fine subcrepitant and crepitant rales, which speedily become 
moist and very abundant. As an ordinary bronchitis, the bases of 
the lungs posteriorly are the parts most involved. The percussion-note 
of both lungs remains clear, but there is apt to be increased resistance. 
The fremitus may be lessened in some areas, increased in others. If 
an area of dulness appears, it may be due to pneumonia or to collapse 
of the lung ; if the former, there is usually an access of fever. 

The sputum contains mucus, pus, occasionally blood-cells, granular 
matter, and sometimes fibrinous casts of the tubes. The micro-organ- 
isms found are the micrococcus lanceolatus, streptococcus pyogenes, and 
staphylococcus aureus et albus. Mixed infections are usually present. 

Plastic bronchitis is a form of bronchitis, usually chronic, the 
characteristic feature of which is the expectoration of fibrinous casts, 
which, when unravelled under water, are found to be solid casts of 
the smaller bronchial tubes. The casts are often tree-like in shape, 
showing that a bronchial tube and its smaller subdivisions have been 
occluded by the casts. 

Persons of all ages are liable to it, but it affects males about twice as 
often as females. 

The subjective symptoms are cough and dyspnoea ; haemoptysis 
occurs in about one-third of the cases (Biermer). 1 The cough occurs 
in paroxysms, which are frequent and severe ; relief follows expecto- 
ration of the casts. 

Hemorrhage may appear only as streaks of blood upon the casts, or 
may be considerable, and follow their dislodgement. The casts them- 
selves when ejected are usually coated with mucus, so that they appear 
as solid masses of sputum ; their arrangement into cylinders may not 
be suspected until they are agitated in Avater. The size of the cylin- 
der varies from that of the little finger to that of a bodkin, but they 
do not often exceed the size of a goose-quill. The larger casts may 
be hollow, but the smaller ones are solid, and are arranged in layers. 
They are whitish or gray in color, and firm in consistence, but become 
softer as the disease improves. Microscopically, the casts are nearly 
structureless, consisting of a fibrillated base, with pus and mucous cor- 
puscles, a few gland-cells, and, occasionally, blood-cells in the outer 
layers. Charcot-Leyden crystals and Curschmann's spirals are found. 

1 Virchow: Handbuch der spec. Path. u. Ther., Bd. v., Abth. 1. 



PLATE XVII 




\ - 1 m 



VJ*; 



FIG. 2. — Posterior Aspect. 




%^ : ^4 












■^= 



Capillary Bronchitis (early stage). 

Rough or sharp breath sounds-expiration in places prolonged. Sonorous, 
sibilant and small moist rales. Local increase of fremitus. 



DISEASES OF THE LUNGS AND PLEURJS. 547 

The acute form is rare, and out of ten cases accepted by Biermer six 
proved fatal. The disease begins A\ r ith fever, dyspnoea appears early, 
severe paroxysms of cough occur, sometimes hemorrhage. Death 
results from asphyxia. Grave symptoms are excessive dyspnoea, 
scanty expectoration, and drowsiness. Copious expectoration is a 
favorable sign. 

The Physical Signs. The casts obstruct the bronchial tubes. There 
is less air entering the part, hence there are diminished fremitus and 
respiratory murmur over the portions of lung supplied by the obstructed 
tubes. If collapse ensues, there is dulness on percussion ; if the casts 
are dislodged, the murmur becomes normal, or but slightly roughened. 
In unaffected portions of the lung resonance is clear or exaggerated, 
and the respiratory murmur remains unaltered. 

Fuller says (quoted by Peacock in Diseases of Chest) that the upper 
portions of the lungs are oftener affected than the lower portions. 

Fetid or Putrid Bronchitis is the name applied to the condi- 
tion in which the sputa have a highly offensive odor and are copious 
and semi-putrid. The odor is said by some to be due to microscopic 
sloughs, and by others to a special bacillus. 

Putrid bronchitis may accompany (1) dilatation of the bronchial 
tubes ; (2) chronic pneumonia ; (3) phthisis or (4) empyema with a 
fistulous communication with a bronchus ; or (5) it may occur indepen - 
dently. The subjective symptoms are cough, irregular fever, and 
occasional chills. The physical signs are those of chronic bronchitis, 
or of bronchitis and the conditions with which it may be associated 
(q. v.). It is diagnosticated from gangrene by the absence of physical 
signs of disintegration of lung-tissue and by the absence from the 
sputum of fragments of lung-tissue and elastic fibres. Nevertheless, 
gangrene of the lung may be the final result of putrid bronchitis. 

The sputa of fetid bronchitis have an odor of gangrene or faeces. 
On standing they separate into three layers. The upper one consists 
of a greenish, fluid, or frothy layer ; the second is sero-albuminous ; 
and the third a thick granular deposit in which are small masses, the 
size of peas (Dittrich's plugs), and flake sconsisting of granular detritus, 
and containing fat-crystals and bacteria, the oidium albicans, and crys- 
tals of leucin and ty rosin. (See Sputum.) 

Infectious Bronchitis. In addition to the bronchitis that attends 
the infectious disorders mentioned above, three forms are seen of an 
infectious nature which are properly classified among the infectious 
diseases. It is proper to refer to them now, as bronchitis is usually 
the most pronounced local manifestation. They are influenza, whoop- 
ing-cough, and hay-fever. The last only will be spoken of at present. 

Hay- fever. Hay-fever is a specific catarrh of the respiratory pas- 
sages, caused by the pollen of certain plants, principally the grasses. 
The attack begins with itching, burning, and lacrymation of the eyes, 
and pain in the brow or eyeballs. Subsequently there is itching or 
pricking of the nasal mucous membrane, frequent sneezing, and an 
irritating watery discharge. The mucous membrane of the nose is 
red and swollen. A similar condition obtains in the throat when that 
is affected. If the disease attacks the bronchial mucous membrane a 



548 SPECIAL DIAGNOSIS. 

bronchitis is set up, which, if it differs at all from ordinary bronchitis, 
is more persistent and attended by greater dyspnoea, with asthmatic 
attacks. 

Collapse of the Lung. Collapse of the lung is a condition pro- 
duced by exhaustion of air from the air-vesicles. It may affect alyeoli 
here and there, or a large section of the lung. Formerly such collapse 
was invariably looked upon as pneumonia, until Legendre and Bailly 
proved by forcible inflation that the air- vesicles had simply collapsed 
from absence of air. Collapse occurs most frequently in the course of 
bronchitis and in cases with feeble respiratory power. The bronchial 
twigs supplying certain air-vesicles, or tubes supplying sections of lung, 
become occluded to such a degree that no air can enter. The air 
already contained in the vesicles then becomes exhausted gradually 
until the vesicles are completely airless. The vesicles or sections of 
lung involved then return to the foetal condiiion. When the collapse 
is congenital the term atelectasis is preferable. Anything which in- 
duces great muscular weakness predisposes to collapse of the lung ; 
hence, in the aged and feeble, in Avasting diseases, and in low febrile 
diseases of long standing, collapse is very apt to occur. But bronchitis 
is the most frequent and direct cause. The secretions which are 
poured out, and the swelling of the mucous membrane, occlude the 
tubes, and if the patient have not strength enough to expel the secre- 
tions, and by forced inspiration expand the collapsing vesicles, collapse 
ensues. 

Diagnosis. The diagnosis of the condition in life is difficult. The 
site of collapse, being airless, is, of course, dull on percussion. The 
respiratory murmur is more likely to be faint or absent than to be 
increased in intensity or approach the bronchial. Nevertheless, there 
is sometimes heard a faint broncho vesicular expiration. 

When oedema is superadded to collapse, moist crepitant rales are 
heard, difficult if not impossible to distinguish from those of pneumo- 
nia. Respiration is embarrassed, and is accompanied by sucking-in of 
the lower part of the chest in inspiration. Sometimes the plug of 
mucus which occludes the tubes becomes dislodged while the physician 
is auscultating, and then the respiratory murmur will be heard, accom- 
panied by a succession of crepitant rales, which disappear after a few 
inspirations. The dull areas, as a rule, are less persistent than those 
of pneumonia ; thus it may be found at successive examinations that 
one area has cleared up and another has become dull. Stress is laid 
by some writers upon the signs of emphysema surrounding collapsed 
areas. But this does not give assistance in the cases in which most 
help is required — cases in which there is diffuse bronchitis with more 
or less oedema. 

Subjectiye symptoms are those of dyspnoea and insufficient oxygena- 
tion of the blood. If these are developed suddenly, and are accom- 
panied by the appearance of dull areas in the lung without bronchial 
breathing, the diagnosis is tolerably certain ; but when scattered lob- 
ules only are involved, the physical signs of collapse are absent, and 
its existence must be a matter of inference. 

From lobar pneumonia the diagnosis is easily made by the difference 



PLATE XVIII, 



FIC. 1. 





Broncho- pneumonia. 

Consolidation in the right upper and the left lower lobes. Physical signs 
of bronchitis over both lungs. 



DISEASES OF THE LUNGS AND PLEUEJE. 549 

in the physical signs, and by the absence in pulmonary collapse of 
inflammatory symptoms, by the lower temperature, and the difference 
in onset. 

The diagnosis from bronchopneumonia, or catarrhal pneumonia, is 
beset with greater difficulties. But here also the low temperature, 
and the fact that the physical signs and the location of the dull areas 
are subject to rapid changes, are of aid in diagnosis. 

The Bronchi, the Alveoli, and Connective Tissue. 

Bronchopneumonia, or Catarrhal Pneumonia, is a pneumonia 
occurring secondarily to bronchitis, and is characterized by the devel- 
opment of areas of consolidation in both lungs and the persistence of 
a bronchitis of the middle-sized or smaller tubes. In proportion as 
the areas of consolidation are large, the symptoms and physical signs 
approach those of lobar pneumonia. It is more common in children 
and in debilitated persons. It is the chief form in infants. 1. It is 
frequently secondary to measles, diphtheria, scarlet fever, and per- 
tussis. 2. As aspiration pneumonia, it occurs when food, septic parti- 
cles, blood, or tissue enter the lungs during the loss of sensibility of 
the larynx in apoplectic, ursemic, or other forms of coma, and in opera- 
tions about the upper air-passages and mouth. It is a fatal complica- 
tion of tracheotomy. 3. It is frequently of tuberculous origin. 

Catarrhal pneumonia, except the aspiration-form, develops gradu- 
ally, and it may not always be easy to mark the point at which the 
bronchitis which precedes merges into pneumonia ; but as a rule there 
are more or less chilliness (rarely a decided chill) and an access of 
fever. There is usually greater prostration than in the lobar form, in 
proportion to the amount of pneumonia present. The pulse is more 
frequent and more likely to be feeble. Cough and expectoration are 
marked symptoms. The sputum is tenacious and glairy, not rusty. 
It contains streptococci and staphylococci in much greater numbers 
than are found in ordinary bronchitis ; fatty epithelial cells, epithe- 
lium, fat-globules, and diplococci. 

Dyspnoea is more extreme than in lobar pneumonia. The respira- 
tions are excessively rapid — 60 to 80 per minute ; cyanosis rapidly 
ensues. The finger-tips become blue, the face dusky. The fever 
does not rise as high as in the lobar form. At first the skin is hot 
and dry ; later it becomes cold and clammy, and in the tuberculous 
form sweats are common. The duration of the disease is usually much 
longer than in lobar pneumonia. 

The physical signs (Plate XVIII.) are those of bronchitis, with here 
and there larger or smaller areas of consolidation, over which the rales 
are finer and closer set ; the percussion-note is dull, and the respiratory 
murmur bronchial or bronchovesicular. An entire lobe may be consoli- 
dated. Areas of collapse and portions more or less oedematous combine 
to make the more complex physical signs. While both lungs are affected, 
they are not usually so to the same extent. It is said that the apices 
are more prone to involvement in this than in the lobar form ; and some 
writers (Osier) look upon it almost, if not always, of tubercular origin. 



550 SPECIAL DIAGNOSIS. 

In the common form seen in infants the symptoms of asphyxia set 
in at variable periods in the course of the disease. General cyanosis 
supervenes. Stupor sets in, the hurried respirations grow shorter and 
more gasping, the pulse becomes excessively rapid and feeble, the ex- 
tremities cool and clammy ; with the stupor the cough abates and the 
breathing becomes more shallow. The lungs fill up with fluid mucus, 
and the child drowns in its own secretions, or cardiac paralysis sets in 
after dilatation of the right heart. 

Diagnosis. The affection is distinguished (1) by its pathological 
antecedents and causal relations ; (2) its gradual onset ; (3) its distri- 
bution in both lungs ; (4) the preponderance of physical signs of bron- 
chitis over those of consolidation ; (5) the extreme dyspnoea and cyan- 
osis with a lower temperature than in lobar pneumonia ; (6) the onset 
of carbondioxide-poisoning ; (7) the long duration and gradual decline. 
The tuberculous form is distinguished by (1) the history of exposure to 
infection or of a focus of infection in the body, glands, or joints ; (2) 
the longer course ; (3) delayed asphyxia ; (4) rapid emaciation ; (5) 
diffused sweats ; (6) physical signs of consolidation and subsequently 
of cavity at the apex ; and (7) absolutely by tubercle bacilli in the 
expectoration coughed up or vomited. I have seen a child aged fifteen 
months, of a tuberculous mother, completely recover. The tuberculous 
form is common in colored infants. 

Bacteriological Diagnosis. Examination of the sputum shows an 
abundance of the streptococci and staphylococci and the special micro- 
organism which belongs to the primary infection, as that of influenza, 
diphtheria, and tuberculosis. 

Lobar Pneumonia, or Croupous Pneumonia. (Plate XIX.) This 
inflammatory affection of the lung may be due to one of many micro- 
organisms (single infection), or it may be a mixed infection. For its 
consideration, the reader is referred to the Infectious Diseases, Chapter 
XX., Part I. 

Chronic Interstitial Pneumonia. Cirrhosis, fibroid phthisis, and 
chronic interstitial pneumonia are names given to a condition of 
chronic induration of the lung, caused by interstitial overgrowth of 
fibrous tissue. Obliteration of the air-vesicles and contraction of the 
lung result from the overgrowth. The bronchi are frequently dilated, 
and cavities and gangrene may occur. The disease is rare except as 
the result of tuberculosis, but it may follow pneumonia and pleurisy, and 
it is said to be caused by inhalation of fine particles of steel or cotton. 
Pneumonohoniosis is the term, first employed by Zenker, for the 
chronic interstitial pneumonia from the inhalation of dust. 

Physical Signs. (See Plates, Bronchiectasis.) Inspection. The dis- 
ease is unilateral. The chest- wall is retracted. The ribs are drawn 
together, so that the interspaces are obliterated. The shoulder is drawn 
over the sunken thorax. The spinal column is curved. The heart is dis- 
placed. It is drawn toward the affected side. If the right lung is the seat 
of disease, an impulse is seen to the right of the sternum ; if the left, the 
precordial area of impulse is increased and extends upward. There is 
no expansion whatever (immobility) of the affected apex or base. The 
lieal thy lung is the seat of compensatory emphysema. (See Fig. 147.) 





\ 



Lobar Pneumonia. 

Consolidation of the right lower lobe. Transmitted bronchial breathing and 
signs of bronchitis over the left lung posteriorly. 



DISEASES OF THE LUNGS AND PLEURA. 551 

Fig. 147. 




Fibroid (tuberculous) phthisis ; right apex. Heart displaced as indicated by oval. 

Palpation. Inspection is confirmed. Fremitus is increased, espe- 
cially at the apex. At the base, pleural thickening lessens the frem- 
itus. 

Percussion. The physical signs show increased density of lung 
tissue, with dulness on percussion, or, over a dilated bronchus, a tym- 
panitic or amphoric note. 

Auscultation. The respiratory murmur is bronchial, or, over a 
dilated bronchus, has a hollow sound. At the base breath-sounds are 
feeble, distant, or absent. Rales are also heard. 

The disease runs a very chronic course, attended by cough, and 
mucopurulent and sometimes bloody expectoration, even hemorrhage ; 
but there is no fever and not much loss of flesh. Dyspnoea occurs on 
ascending heights only. Dilatation of the right heart is likely to 
ensue, with cardiac murmurs and increased lateral dnlness and increase 
of dyspnoea. Death is hastened by the disease, and is often brought 
on by acute pneumonia. 

In pneumonokoniosis (also known as anthracosis, coal-miner's dis- 
ease ; siderosis, from metallic dust ; chalicosis, from mineral dust, as 
m stone-cutter's phthisis) there is a history of exposure to the irri- 
tating particles for a considerable period, during which time cough 



552 SPECIAL DIAGNOSIS. 

develops, gradually increases, and the general health fails. Emphy- 
sema simultaneously arises, causing dyspnoea.' The patients wheeze, 
cough in paroxysms, and expectorate sputum Avhich contains the dust- 
particles. In anthracosis it is black. On microscopical examination 
the special dust-particles are often found. The symptoms of emphy- 
sema and chronic bronchitis predominate. Tubercular infection may 
take place late in the disease. 

Pulmonary Tuberculosis. For convenience of diagnosis the specific 
inflammation of the lungs caused by the bacillus tuberculosis will be 
considered in this section. If a strict etiological classification were 
followed, it would be considered among the infectious diseases. 

Clinically, we see tuberculosis in the lungs manifesting itself in one 
of the forms of acute pneumonic phthisis, acute miliary tuberculosis, 
and chronic ulcerative phthisis. (See Chapter XX., Part I.) 

Definition. Tuberculosis of the lungs, pulmonary phthisis, and 
consumption are names applied to an infectious and mildly contagious 
disease of the lungs, caused by the tubercle bacillus, appearing in an 
acute and chronic form, and characterized by cough, fever, sweats, 
more or less rapid emaciation, purulent expectoration containing elastic 
fibres, and tubercle bacilli, and by peculiar physical signs. 

Acute Pulmonary Tuberculosis, Acute Phthisis, Acute 
Pneumonic Phthisis, Galloping Consumption, may be primary, or 
be secondary to a localized area in the lung, causing rapid infection, or 
to tubercular pleurisy, tubercular peritonitis, or to tuberculosis of some 
other organ. Its onset is usually marked by cough, fever with or 
without chills, dyspnoea, and sometimes haemoptysis. The fever rises 
to 103° or 104°, and is of a continued type (lobar-pneumonic form), 
or rapidly assumes a hectic type, accompanied by restlessness and ex- 
hausting night-sweats, anorexia, anol rapid emaciation. Prostration is 
extreme, but the mind is at first clear anol the spirits cheerful. Cough 
increases, the expectoration, at first mucoid and scanty, but often tinged 
with blood, becomes more copious and mucopurulent. The bowels 
may be loosened or constipated. The urine may show the cliazo- 
reaction. 

When death takes place without more decided pulmonary symptoms 
the tuberculosis has been seconolary to tuberculosis elsewhere, or death 
is the result of a general miliary tuberculosis. 

When the acute pulmonary tuberculosis is primary, the character of 
the disease is soon maole clear by the early development of consolida- 
tion of the lungs, usually of an apex first, rapidly followed by soften- 
ing and the formation of cavities. The sputum becomes mucopuru- 
lent, is frequently streakeol with blood, and pure blood is often coughed 
up. The sputum contains yellow elastic tissue and abundant tubercle 
bacilli. The patient often presents a cachectic appearance ; emaciation 
has been very rapid, and has reached an extreme degree ; there is fre- 
quently a red flush about the cheek-bones, which, with the bright eyes, 
contrasts strongly with the hollow cheeks and temples, and the white 
wasted hands and clubbed fingers with bluish nails. 

The patient's mental attitude is often peculiarly and characteristi- 
cally hopeful. He expresses himself as better each olay, though he is 



PLATE XX. 



FIG. 1. — Anterior Aspect. 



F+^X 




FIG. 2.— Posterior Aspect. 




Acute Pulmonary Tuberculosis. 

Consolidation of the entire right upper lobe and of the left apex. 



DISEASES OF THE LUNGS AND PLEURAE. 553 

occasionally subject to despondency, and is sure that if he could only 
gain a little strength he would soon be well. 

Sometimes, especially in children, the disease is latent. The patient 
suffers from weariness, the cheeks flush easily, the pulse is readily dis- 
turbed, there are nocturnal fever and occasional sweats. Emaciation 
proceeds very gradually, and a long time may elapse before any dis- 
ease is demonstrable. 

In a few cases the cerebral symptoms are so pronounced as to mask 
the pulmonary, and in other cases there is actual coincident involve- 
ment of the cerebral meninges. 

The physical signs (Plate XX.) are those of consolidation, often with- 
out conjoint pleurisy. The apex is usually first invaded. There are 
diminished movement, increased fremitus, and dulness on percussion. 
At first the breathing is bronchovesicular. It rapidly becomes bronchial. 
At first small moist rales are detected. Later they become large and 
gurgling. A pleural friction may be heard. It may be first heard above 
the spine of the scapula behind, above the clavicle in front, or high up 
in the axilla. The upper lobe of the right lung may be affected first, 
or the anterior portion of the middle lobe. The physical signs may 
be observed first in the. axillary region of either side. The consoli- 
dation extends to the remainder of the lung, being preceded by phys- 
ical signs indicating gradual encroachment upon the air-containing 
structure. The respiratory murmur is harsh, but soon becomes 
bronchovesicular and then bronchial. (Lobar-pneumonic form.) As 
consolidation progresses in the middle and lower portions of the affected 
lung, signs of cavity or multiple cavities appear in the upper. (The 
whole of a lobe may be the seat of small cavities filled with muco- 
purulent or purulent fluid.) Cavernous breathing and pectoriloquy, or 
the bronchial sniff of consolidation, become more pronounced. The 
dull note of consolidation is relieved by a dull tympanitic or full tym- 
panitic note. Now moist rales of all degrees are heard. (Broncho- 
pneumonic form.) Above they are gurgling ; below, small and large 
moist rales. If the progress is not too rapid throughout the lung first 
affected, signs of invasion are found in the remaining lung, usually at 
a point corresponding to the primary focus in the original lung. The 
apex, therefore, is first invaded in most cases. Infection of the second 
may begin earlier than the signs in the first lung would lead one to 
anticipate. The rapid invasion of one lung compels compensatory 
emphysema of the other. The increased movement, with harsh or 
puerile breathing, without change in fremitus or in pitch and tone on 
percussion, masks any small consolidations. 

The expectoration becomes more purulent as the disease progresses, 
and may be blood-tinged. It is copious and possesses some fetor. It 
is found to swarm with bacilli and to contain yellow elastic tissue. 
Hemorrhage may take place. The general symptoms become more 
alarming. The fever becomes of a hectic type. The patient rapidly 
emaciates. Cyanosis is shown in the dusky countenance and blue 
finger-tips. The exhaustion becomes extreme. Pallor, with flushed 
cheeks and an anxious countenance, is seen. The sweats are profuse. 
The appetite is lost. Diarrhoea may set in. Remissions may take 



554 SPECIAL DIAGNOSIS. 

place, even in acute cases ; for a time the fever and more aggravated 
pulmonary symptoms are in abeyance. The typhoid state ensues in 
some cases. Death takes place from exhaustion and heart-clot or from 
meningeal tuberculosis. The duration is from two to six weeks. 

Diagnosis. In the earliest stages, before the invasion of new terri- 
tory is pronounced, the cases are involved in doubt. It may be con- 
founded with pneumonia until the sputum is secured and bacilli are 
found. 

In pneumonia we have the pronounced rigor, the rapid rise of tem- 
perature, the altered pulse-respiration ratio, the hot, dry skin, the sticky, 
viscid sputum, containing the pneumococcus, the peculiar changes in 
the urine, leucocytosis, the occurrence of herpes, the termination by 
crisis, to point to the nature of the process. Emaciation is not 
marked ; there are no such profuse sweats as the repeated drenchings 
we see in pneumonic phthisis ; anaemia is not so pronounced. Then 
cavity-formation does not take place, or at least rarely. In pneumonia 
the fever is of a continued type ; in phthisis it is often intermittent 
or remittent. The sputum is more purulent in acute pneumonic 
phthisis. Finally, the history of exposure to infection, the primary 
occurrence of tuberculosis elsewhere, the secondary occurrence of tuber- 
culosis in other organs after the lung-invasion, the longer duration — 
aid in determining the true affection. Inoculation of animals may be 
resorted to in doubtful cases. 

Acute miliary tuberculosis (pulmonary type) is attended by 
high fever, rapid emaciation, hurried breathing, rapid pulse, duskiness 
of face and extremities, more or less stupor, delirium, and the develop- 
ment of the typhoid state, with prostration and the occurrence of pro- 
fuse sweats. Intestinal symptoms, as flatulency and distention, may 
be pronounced, and diarrhoea may form a prominent feature. Physical 
signs are negative or are those of bronchitis. There is resonance or 
hyper-resonance on percussion. The latter is not uncommon. The 
onset is abrupt or may follow a period of malaise. In some instances 
the tuberculous process is more advanced in some situations than in 
others, giving rise to special local symptoms. Thus, recently, a patient 
was admitted to the Presbyterian Hospital with stupor and moderate 
delirium. He had fever, rapid pulse and breathing, and a peculiar 
dry, harsh skin. There were albuminuria, casts and blood in the 
urine, and it was thought he had uraemia. The temperature-range 
was irregularly intermittent. The diagnosis was established later be- 
cause of the development of undoubted secondary tuberculosis in 
other organs. At the autopsy general tuberculosis was found, with 
primary tuberculous ulceration in the bladder, the ureters, and renal 
pelves. 

Diagnosis. Hurried breathing and cyanosis are distinctive feat- 
ures, out of all proportion to the physical signs, and, on this account, 
of diagnostic significance. It must be distinguished from typhoid 
fever, septicaemia or pyaemia, and malignant endocarditis. It is dis- 
tinguished from typhoid fever by the absence of successive stages in 
the course of the disease ; in typhoid fever the evolution of the disease 
is more characteristic than its symptoms. The headache of the first 



DISEASES OF THE LUNGS AND PLETJRjE. 555 

week finally disappearing, is noteworthy. The special range of tem- 
perature, the onset, the fastigium, and the defervescence at definite 
periods in the evolution of the disease, are of diagnostic value. Cyan- 
osis is more constant and marked in tuberculosis. The skin and capil- 
laries have more tone in typhoid fever than in tuberculosis, at least in 
the first two weeks. Hyperemia follows irritation in typhoid ; pallor, 
with duskiness, in tuberculosis. The eruption, with its specific mode 
of development, belongs to typhoid fever alone. The stools, the en- 
larged spleen, the vascular tone are suggestive of typhoid fever. The 
spleen enlarges earlier in the disease in typhoid fever. Bacteriological 
examination may be of service. The occurrence of intestinal hemor- 
rhage, pointing as it does to typhoid fever, is a welcome sign in cases 
in which the diagnosis is obscure. I have never seen it in tuberculo- 
sis. In typhoid fever the reflexes (knee-jerk) are never absent ; in 
tuberculosis, if the meninges are involved, they are variable, present 
one day, absent the next. The diazo-reaction in typhoid is of some 
service, although it also occurs in tuberculosis. (See Urine.) It does 
not come on until later than the fifth day in typhoid fever. It disap- 
pears at a certain time in the involution of typhoid ; it continues in- 
definitely in tuberculosis. (See Chapter XIX., Part I.) 

The distinction of tuberculosis from septicaemia or pyseniia and 
malignant endocarditis is often difficult. We must search for local 
areas of septic or pysemic infection. The ears, the teeth, the bones, 
the veins, the heart, the pelvic organs in females, the rectum, the 
genito-urinary tract —must be carefully examined. Hemorrhagic in- 
farcts, or metastatic abscesses, may be found which point to the origi- 
nal conditions. The eye-ground may show hemorrhages. The skin 
and mucous membranes may exhibit minute capillary hemorrhages or 
infarcts. They are the size of a pin-head, do not disappear on press- 
ure, and are not elevated. The spleen is more likely to be enlarged 
in the septic affections. The respirations are not so rapid as in tuber- 
culosis. Cyanosis is a distinctive feature of tuberculosis. The physi- 
cal signs of endocarditis may be determined, and subsequently embo- 
lism or thrombosis prove the nature of the process. 

Chronic Tuberculosis, Chronic Ulcerative Phthisis. Chronic 
tuberculosis or phthisis is much more common than acute tuberculosis, 
from which it is distinguished by its slow progress and by periods of 
remission, during which the disease may be arrested temporarily or 
permanently. 

It may begin in a variety of ways. The most common mode of 
origin is in an ordinary bronchitis with which pleurisy is occasionally 
associated. Previous to this the patient may have been in good health, 
but generally the health has been impaired for some time. The bron- 
chitis may be simple or part of influenza, measles, whooping-cough, or 
some other specific disease. 

The bronchitis usually proves obstinate, and by and by there is 
found at the apex of the lung a small area over which, on percussion, 
there is increased resistance, with slight impairment of resonance, as 
compared with the other side ; the respiratory murmur is broncho- 
vesicular, sometimes jerky in rhythm, and the vocal resonance and 



556 SPECIAL DIAGNOSIS. 

fremitus slightly increased or unaltered. Such physical signs are met 
with more frequently at the right apex than at the left, and oftener in 
the suprascapular fossa than anteriorly. The next most frequent seat 
is probably between the clavicle and second rib anteriorly. 

The patient will be found to have lost strength, and usually some 
weight. There is often a slight evening rise of temperature, and occa- 
sionally nocturnal perspirations. The appetite is impaired, and. ano- 
rexia may exist. Cough is rarely absent, especially during the night 
or on waking in the morning ; it may, however, be so slight as appar- 
ently to have escaped the notice of the patient. When characteristic 
it is dry and hacking. Expectoration is scanty and mucoid, but occa- 
sionally it may be tinged with blood. It should be remembered that 
children and old persons sometimes do not expectorate, and that, as a 
rule, Avomen are more inclined to suppress expectoration than men. 
No tubercle bacilli may be found in the sputum after repeated exami- 
nation ; but if examinations are continued, they will appear sooner or 
later. 

Instead of developing after a bronchitis, as we have just described, 
it may set in suddenly under the guise of a pneumonia, more frequently 
of the catarrhal form. The symptoms and physical signs do not differ 
essentially from those of pneumonia, except that the expectoration is 
more likely to be profuse, mucopurulent, and blood-streaked, and 
bacilli are found in it ; the fever is more hectic in type, and night- 
sweats are common. The consolidation is found at the apex. After 
the patient convalesces from such an attack he continues weak, does 
not gain flesh readily, still has a cough with expectoration, evening 
fever with occasional night-sweats, and an area of consolidation usually 
at an apex of the lung. Over this area, in addition to the usual signs 
of consolidation (bronchial or feeble breathing, dulness, etc.), moist or 
dry subcrepitant rales are heard. 

In some cases fever, emaciation, and weakness progress for some 
time before pulmonary symptoms arise. 

In still other cases the invasion of the disease is by sudden haemop- 
tysis, which is oftener copious than not. Several such hemorrhages 
may occur in rapid succession, or there may be only one. Moreover, 
its disappearance may not be followed, or at least not immediately, by 
any farther pulmonary symptoms or physical signs ; more commonly, 
however, it is followed by fever, cough, expectoration, and physical 
signs of incipient consolidation, usually at the apex. 

In still other, but rarer cases, the pulmonary disease is latent, being 
marked by gastric or peritoneal symptoms, or by a general ansemia. 

By whatever path invasion comes, the physician should be on the 
lookout for it, especially in a young adult predisposed by heredity or 
environment to tuberculosis. The recognition of the disease in its 
early stage requires the greatest skill, which in turn is recompensed 
with the highest reward, since the disease is then curable. 

The further progress of a case of tuberculosis of the lungs, after con- 
solidation has once become manifest, is very variable. It may be 
arrested at this point permanently, cure' resulting from cicatrization. 
More frequently there is temporary arrest of the process ; fever lessens 



PLATE XXI. 



FIG. 1. — Anterior Aspect. 



F+. 



•A. 



^A. 




V 






FIG. 2.— Posterior Aspect. 



Mr4 




Chronic Pulmonary Tuberculosis. 

Consolidation with cavity formation. Chronic pleurisy with loss of respiratory 
movement of lung margins. Retraction. 



DISEASES OF THE LUNGS AND PLEUBjE. 557 

or ceases entirely, the pulse resumes its normal rate, appetite improves, 
and there is a gain in flesh and strength. Cough and expectoration 
are more likely to persist than the other symptoms, but with the other 
improvement they diminish in frequency and copiousness. There are 
fewer rales, but the signs of consolidation are still present, though 
there is no further extension of the process. Often, after a cavity has 
been found, the disease is arrested, or progresses very slowly. 

After a longer or shorter time, as the result of reinfection from the 
old focus excited by acute bronchitis or by some depressing influence, 
the tuberculosis is relighted, so to speak, and runs much the same 
course, the lung being left more diseased and the general health worse 
after every such attack. Nevertheless, there may be long intervals 
between such attacks, the patient in the meantime continuing in fair 
health. Thus the disease may linger or recur for years, the patient 
not ill enough to be confined to the house, and not well enough to 
stand hard work or great exposure. Slowly, by ulceration and suppu- 
ration, the lung- tissue is wasted and cavities are formed. Before there 
are large cavities at an apex the base of the same lung becomes consol- 
idated by the production of tuberculous material, and before one lung 
is extensively diseased the apex of the opposite lung is attacked, the 
process being repeated in it if the patient lives long enough. Instead 
of reinfection from an old focus, new infection may take place, giving 
rise to the old train of symptoms, or setting up more acute disease. 
During this time the patient is liable to an attack of acute pneumonia, 
pleurisy, bronchitis, or general miliary tuberculosis. He is also liable 
to sudden death by hemorrhage. In a number of cases the intestines 
and peritoneum become affected, and abdominal pain and diarrhoea 
are superadded as symptoms. 

As a rule, the patient gradually sinks. The later stages are marked 
by increasing cough and dyspnoea, which are very distressing and pre- 
vent sleep. Expectoration is more copious, purulent, and is raised 
with increasing difficulty. 

The appetite is poor and capricious, or anorexia is complete. The 
heart becomes more and more feeble, the fever is hectic and accom- 
panied by exhausting night-sweats, the feet and limbs swell, and acute 
cramp-like pains are felt in the legs, probably caused by thrombosis of 
the veins. 

Emaciation is extreme, scarcely anything but skin and bone being 
left. Death occurs from perforation of an intestinal or gastric ulcer, 
from hemorrhage, or more commonly from exhaustion, and from 
asphyxia caused by oedema of the lungs. 

The physical signs (Plate XXI.) depend upon the lesions. It is often 
possible to detect all stages of the tubercular process, from early consoli- 
dation to large cavity, in the same patient. The signs of consolidation 
have been sufficiently dwelt upon. When softening begins, the percus- 
sion-note continues dull and the breathing bronchial ; but it is often 
difficult to make out the quality of the breath-sounds because they are 
feeble and obscured by numerous moist crackling rales and moist sub- 
crepitant rales from disintegration of lung-tissue and bronchitis. After 
the patient has coughed several times and expectorated, and then takes 



558 SPECIAL DIAGNOSIS. 

a long breath, the quality of the breathing becomes perceptible. As 
the lung-tissue is further softened and removed by expectoration cavi- 
ties are formed. These, if large enough and superficial, give a tym- 
panitic note on percussion, and, if there is communication with a bron- 
chus, a cracked-pot sound. The breath-sounds are hollow and the 
rales are bubbling and gurgling, or large and mucous. 

The normal vocal resonance is replaced by bronchophony and pec- 
toriloquy. Tactile fremitus may or may not be increased. (See Cavi- 
ties.) 

But if the walls of the cavity are thick from indurated tissue, the 
percussion-note will be dull and the breathing bronchial. If the tissue 
composing the wall is less thick and dense, percussion produces a 
wooden sort of resonance. If much normal lung-tissue intervenes, the 
percussion-note will be clear. 

As tuberculosis of the lungs progresses, the clavicles and ribs be- 
come more and more prominent from the loss of fat, and local flatten- 
ing of the chest, with impaired expansion, marks the seat of the disease. 

The Diagnostic Features. The striking phenomena of tuberculosis 
which are considered in the diagnosis are emaciation, anaemia, fever, 
cough, dyspnoea, chest-pain, hemorrhage, the expectoration, and the 
objective symptoms. Of less diagnostic value, but important as col- 
lateral data, are the aspect, the occurrence of vomiting and diarrhoea, 
and of symptoms of secondary tuberculosis in other organs. Age and 
occupation may, to a certain extent, aid in the diagnosis. 

Emaciation. This is always seen, even in acute forms of tubercu- 
losis. It is rapid in the acute, slow and progressive in the chronic 
forms. In the latter there may be a temporary improvement in this 
respect. It must not be confounded with muscular atrophy, and the 
emaciation of carcinoma, diabetes, anorexia nervosa, and other exhaust- 
ing diseases. Anosmia is always pronounced. It may be associated 
with leucocytosis if there is cavity formation. The reduction of red 
cells and diminution of haemoglobin are marked. Fever. This symp- 
tom is always present. The temperature should be taken every two 
hours for a time, to determine accurately the degree and course. It 
may be intermitting, remitting, or continuous. It may be intermitting 
in some acute forms, the morning fall reaching, or going below, normal. 
The difference between morning and evening temperature may not be 
more than a degree. In the acute form it is high and continuous, and 
soon may be attended by the typhoid state. In the more chronic cases 
it may be intermittent at first, then continuous, and finally intermittent 
again. In the later stages the intermitting fever is due to a mixed 
infection, or sapraemia, from the purulent contents (staphylococcus and 
streptococcus infection) of the lung cavities. 1 (See Fig. 148 and Fig. 
14D). The intermittent fever of the early stages has frequently been 
mistaken for malaria. (See Fever.) The occurrence of fever in a 

1 Leyden has pointed out that intermitting fever is part of the tuberculous process, 
and not a streptococcus or staphylococcus infection, as formerly held, because pus micro- 
organisms are not found in the purulent contents of cavities, and because in other 
forms of tuberculosis, as empyema or joint-disease, they are notably absent, and yet 
such form of fever exists. — Deutsche medicin. Wochenschrift, Sept. 14, 1894. 



DISEASES OF THE LUNGS AND PLEURJE. 



559 



patient who has been losing flesh, and is otherwise in poor health, 
excludes cancer and diabetes and other afebrile causes, and points 
strongly to tuberculosis. It must not be forgotten that in chronic 
tuberculosis in the aged the temperature may not rise above 100° ; 
often, indeed, it is subnormal. 



Fig. 148. 




Continued fever of tuberculosis. 



Fig. 149. 



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Intermitting fever of tuberculosis. 

We must consider, therefore, that fever, the cause of which is not 
obvious, may be due to tuberculosis ; and that if, when such probable 
causal conditions as gastro-intestinal catarrh or infectious disorders 
(malaria) and suppurations are eliminated, the fever still persists, then 
the fever is probably of tuberculous origin. 

Sweats. Frequent sweating may be the first symptom complained of 
by the patient. It may occur with the tripod of symptoms of the 
intermitting febrile range — chill, fever, and sweat. It would be likely 
to occur at night under these circumstances. It may occur at any 
time, however. " Night-sweats " are alarming to the mind of the 



560 SPECIAL DIAGNOSIS. 

laity, and are really of diagnostic significance. The perspiration 
awakens the patient at night because it is so profuse. It may be only 
moderate, not rousing the patient until morning. It may be general 
or local. Local sweats are confined to the head and neck. Anwmia. 
This quite rapidly becomes marked. It is recognized by the color of 
the surface and by an examination of the blood. When collateral 
inflammation is present, leucocytosis is seen. Cough. Cough is one 
of the earliest symptoms. It may be the only symptom for some time. 
It is often dry and hacking at first and may continue so for a long 
time. Later it is accompanied by mucoid and then mucopurulent 
sputa, which contain the characteristic elements. (See Sputum.) Dysp- 
noea is almost always present. The degree varies with the association 
of fever. When the latter is present dyspnoea is more pronounced. 
It is more pronounced in acute cases. In miliary tuberculosis the 
frequency of respirations that attends the dyspnoea is out of all pro- 
portion to the physical signs. In this form cyanosis is more marked. 
In chronic localized phthisis the dyspnoea may only occur on exertion, 
after eating, or upon excitement. The bloodless lips may have a con- 
stant bluish hue. The fingers are dusky and become " clubbed." In 
the later stages the dyspnoea is constant and in proportion to the extent 
of involvement of the lungs and the degree of fever. Although of 
diagnostic significance only when associated with other symptoms, it 
is most distressing, and is the cause of constant demand for relief. 

Chest-pain. This is due to localized pleurisy or to myalgia. The 
latter may be seated in muscles strained by coughing. Pleuritic pains 
may occur in any situation, and vary in position from time to time. 
They may be due to extensive inflammation or to tuberculous pleurisy. 
Constantly recurring and unilateral chest-pains, with or without signs 
of pleurisy, with cough and emaciation, are significant of the disorder 
under consideration. (See Pain.) 

Hemorrhage. This symptom is alarming, and, in the large majority 
of cases, is due to pulmonary tuberculosis. It may mark the onset of 
the acute disease, and continue irregularly throughout its course or 
recur several times before the advent of more common symptoms of 
the chronic form. It may occur at intervals of a few months or a 
year, before emaciation, cough, and characteristic expectoration set in, 
or before bacilli are found in the sputum. Each attack is attended 
by fever, usually, and followed by anaemia and prostration. If hemor- 
rhage of the lungs (see Symptoms) occurs in a young adult without 
cause (as aneurism or cardiac disease, etc.), it must be looked upon 
with suspicion. The likelihood of tuberculosis is increased if the 
bleeding occurs in a patient of tuberculous aspect in whom a family 
history of tuberculosis is found, and who has been exposed to infec- 
tion. In the aged it may occur from a localized area of disease. 
Hemorrhage is also common in the late stages of tuberculosis. It is not 
at this period of diagnostic value as to the primary cause. It is usually 
due to the erosion of an artery in a cavity. Hemorrhage also occurs 
in tuberculosis daring the quiescent period. The progress of the disease 
is arrested. The discharge of blood is accompanied by the expectoration 
of pulmonoliths, calculi formed by the degeneration of caseous areas. 



DISEASES OF THE LUNGS AND PLEURjE. 561 

Vomiting (see Gastrointestinal Disease) is a symptom which is often 
present in the early stages of tuberculosis of the lungs, and frequently 
masks the true condition. The vomiting may lead to the belief that 
a local gastric catarrh or diarrhoea is to blame for the general symp- 
toms. The occurrence of fever with the gastric symptoms should lead 
to an examination of the lungs. 

The occurrence of diarrhoea and symptoms of tuberculosis in other 
organs may thoroughly establish the diagnosis in tuberculosis of the 
lungs with otherwise obscure pulmonary symptoms. The intestinal 
discharges may contain tubercle bacilli, or they may be found in the 
urine, in joint-suppuration or glandular enlargement. 

The Sputum (q. v.). The diagnosis is absolute when tubercle bacilli 
are found in the expectoration. Nummular sputa are more common 
in phthisical excavation. The sputum is discharged in tough coin- 
shaped masses, which sink when expectorated into a vessel containing 
water. Fragments of lung-tissue (yellow elastic) point to tuberculo- 
sis, bat are possible under other circumstances. 

The Physical Signs. The aspect of the patient is always suggestive, 
and is an aid to the recognition of the condition. The tuberculous or 
phthisical chest, the long neck and arms, the pale face, the occasional 
hectic flush, the clubbed fingers, the emaciation of the many subjects 
we see in our infirmaries, fix in our minds a composite picture the 
recognition of which goes far to diagnosticate the insidious disease. 

The objective signs point to an invasion of air-containing structure 
by solid material, with collapse of lobules, leading to consolidation, 
followed by cavity-formation, and in both stages by the occurrence of 
pleurisy. Local contraction (flattening) and impaired movement at an 
apex, with inspiratory depression above the clavicles, with suppressed 
breath-sounds and prolonged expiration, with impaired resonance, are 
the earliest signs of tuberculosis. In the chronic cases, contraction, 
impaired movement, dulness and increased resistance from thickened 
pleura may override the signs of consolidation. ISTo one physical sign 
is of diagnostic significance. The combination of signs, and the orderly 
procession by which they advance as the physical conditions progress, 
are the most diagnostic. 

The Size of the Lung. In the diagnosis of pulmonary tuberculosis 
the physical examination must be directed to a determination of the 
size of the lung, and of the extent of its expansion, by which we judge 
of the amount of air entering the lung, as well as to the presence of 
consolidation. 

The tuberculosis process is associated with diminution in the bulk 
of the lung usually. We can estimate the size and the degree of ex- 
pansion by inspection, palpation, and percussion. The so-called dia- 
phragm-phenomena is studied and the X-rays employed. Any dimi- 
nution in the excursion in the shadow of the diaphragm is evidence of 
diminished bulk of the lung or of diminished expansion. By palpa- 
tion, with mensuration, measurements are taken. By percussion we 
estimate the lung boundaries. The degree of expansion can be deter- 
mined by securing the limits of liver dulness and cardiac and splenic 
dulness in ordinary breathing, and then at the end of full inspiration 



562 SPECIAL DIAGNOSIS. 

and expiration. Valuable information is thus secured. Of course, 
employing inspection and palpation the two sides of the lung must be 
compared. Percussion enables one to determine fairly early the pres- 
ence of consolidation. In thin subjects the change in the note is more 
readily elicited than in fat or muscular subjects. 

On auscultation in the early stage of tuberculosis roughness of 
respiratory murmur with prolonged expiration, feeble respiratory mur- 
mur, and jerking or cog-wheel respiration are common signs. These 
signs change gradually into bronchovesicular and then bronchial types 
of breathing. Crackling rales or clicking sounds and consonating rales 
attending these modifications of breath-sounds are of the greatest diag- 
nostic importance. They must be brought out frequently by cough 
and then full inspiration. 

The Site of the Lesion. The situation of the physical signs is diag- 
nostic. Percussion should be directed especially over those parts of 
the lung in which an infection is liable to occur, as the clavicular and 
subclavicular spaces, the anterior border of the upper lobe, the tongue- 
like part of the left upper lobe, which overlaps the heart, the supra- 
spinous space, the upper interscapular region, and the upper borders 
of the lower lobes posteriorly. The latter is best secured by having 
the patient place the hand of the arm of the side percussed on the 
shoulder of the opposite side. The scapula is thus removed from the 
surface of the lung to be examined. 

It is necessary also to consider carefully the general conditions. 
We inquire the age, adolescence and early adult life being the common 
periods in which pulmonary tuberculosis develops. The occupation, 1 
the history of exposure to the disease, the history of predisposition to 
tuberculosis in the family, the history of previous, now arrested, tuber- 
culosis, as in joint-disease, or glandular tuberculosis (scrofula), are 
data deserving special consideration, as they may furnish corroborative 
evidence of the presence of the disease. 

Diagnosis. The presence of tuberculosis is presumed upon in a 
patient with pulmonary symptoms— as a hereditary predisposition, 
abnormalities in the form of the chest and imperfect development, or 
hypoplasia of the circulatory organs. If the patient is under weight 
and has a poor appetite, and at the same time is undergoing unusual 
strain or anxiety, the possibility of tuberculosis is increased. Often, 
before the physical signs of tuberculosis can be established, the shrewd 
physician will fear recurrence of tuberculosis if there are signs of 
anaemia, progressive loss of weight, slight fever, disturbed digestion, a 
frequent pulse, and persistent and localized bronchial catarrh. The 
examination of the lungs, the examination of the sputa, and the tuber- 
culin test must be employed as soon and as often as practicable. (See 
Diagnosis of Tuberculosis, Chapter XX., Part I.) 

The diagnosis is established by finding tubercle bacilli in the sputum. 
Their absence, in spite of the most careful search, is against the tuber- 

1 Several undoubted instances are recorded in which hospital residents and young 
physicians working in laboratories in which tuberculosis is studied, or constantly ex- 
it mining sputum, have been infected in the course of their studies. 



DISEASES OF THE LUNGS AND PLEURA. 563 

culous origin of the disease. (See Diagnosis of Tuberculosis, Chapter 
XX, Part I.) 

In subsequent chapters the differential diagnosis of tuberculosis and 
other diseases will be pointed out. It must not be forgotten that the 
disease may set in as the terminal affection in many diseases. Thus, 
in diabetes, in insanity, in chronic cerebral or spinal disease, and in 
other affections, tuberculosis may develop insidiously, and finally cause 
death. 

It must be distinguished from chronic gastric disorders, and partic- 
ularly anorexia nervosa. It must not be confounded Avith malaria. 
It must be distinguished from simple anaemia, the cause of which may 
be recognized with difficulty. It must be distinguished from chronic 
bronchitis with bronchiectasis, from pulmonary gangrene and carci- 
noma. Finally, it must not be mistaken for cancer of the oesophagus 
and aneurism of the aorta, two divergent conditions which may have 
pulmonary symptoms simulating phthisis. 

Gangrene of the Lung. Gangrene is a rare disease of the lung, 
and, like abscess, always secondary. It may be produced by any cause 
which so obstructs the circulation that a portion of the lung dies in 
bulk. The gangrene may be circumscribed or diffused ; it results 
most frequently from pneumonia, but may be due to injury, to a gen- 
eral septic condition, or to embolism. It is rather frequently met with 
in the insane, possibly owing to particles of food which have found 
their way into the lung. Aspiration bronchopneumonia, bronchiectatic 
and tuberculous cavities, sometimes lead to gangrene. Gangrene in 
the lung, as elsewhere, occurs in diabetes. 

Symptoms. When it occurs in the insane, or is of embolic origin, 
it may remain latent, and in septicaemia it may be overlooked, on 
account of the general symptoms. In well-marked cases, however, 
the symptoms are characteristic. Symptoms and physical signs of 
pulmonary disease precede the specific symptoms of gangrene. With 
the onset of a moderate fever haemoptysis may occur at once or be 
preceded by the expectoration of a brownish, purulent sputa having a 
most intense and persistent gangrenous odor. It contains fragments 
of lung-tissue, altered blood, and putrid debris. (See Sputum.) It 
separates into the three characteristic layers in a conical glass. The 
fetor of the breath and the characteristic sputum is diagnostic. 

The disease usually occupies the lower or middle lobe of the lung. 
The physical signs are those of cavity. The disease could with diffi- 
culty be distinguished from abscess were it not for the characteristic 
sputum, though in gangrene there is greater tendency to a general 
septic condition, with profuse sweats and collapse. 

Abscess of the Lung. Abscess of the lung may originate in causes 
outside the lung, or in causes within the lung. To the former class 
belong those produced by suppurating bronchial glands, abscess of the 
mediastinum opening into the lung, cancer of the oesophagus with 
ulceration, and abscess of the liver, suppurating hydatid cyst, or sub- 
diaphragmatic abscess in general, bursting into the lung. Intra-pul- 
monary causes are tubercle, septic emboli, in which case the abscesses 
are multiple and subpleural, and pneumonia. In the aspiration form 



564 SPECIAL DIAGNOSIS. 

of lobular pneumonia abscesses occur. Rarer causes are the presence 
of tumors and obstruction of the bronchi. 

Abscess of the lung is therefore always secondary. Its diagnosis 
depends upon the demonstration of a consolidation in which a cavity 
subsequently forms, taken in connection with the history pointing to a 
definite cause. The sputa are copious, purulent, often odorless, some- 
times offensive, but always without the fetor of gangrene. They 
contain elastic fibre, but no bacilli except in tuberculous cases. (See 
Sputum.) In embolic abscess the signs of pleural friction can only be 
detected at times. Of course, the constitutional symptoms of suppura- 
tion are present. 

The Degenerations. 

Emphysema. Emphysema consists in an " excessive, permanent, 
and unnatural distention of the air-cells," or in " extravasation of air 
into the interlobular or subpleural cellular tissue." (Lsennec.) 

Emphysema may be unilateral or bilateral. Local and unilateral 
forms are usually compensatory. Bilateral emphysema may be hyper- 
trophic or atrophic. 

It is more common in men than in women. Its symptoms are more 
common in childhood and after middle age. Two factors are essential 
in its causation. First, defective development of the elastic tissue of 
the lungs. Second, increased intra-alveolar air-pressure. The latter 
is due to a number of causes. In childhood, no doubt, nasal and naso- 
pharyngeal obstructions are operative. In adults occupations which 
necessitate continuous and severe muscular effort, especially if coupled 
with forced expiration with closed glottis, act as causes. Such occupa- 
tions are blacksmithing and playing upon wind instruments. Diseases 
which cause much coughing or respiratory effort, such as chronic bron- 
chitis and whooping-cough, act in the same manner. Chronic mitral 
valvular disease and the lessened elasticity of the lung-tissue of ad- 
vancing age both favor congestion of the lung, and thereby predispose 
to emphysema. The disease is hereditary ; several members of a 
family are affected. It occurs in many in childhood, is in abeyance 
in adult life, and reappears in old age. 

Symptoms. The prominent symptoms in hypertrophic emphysema 
are dyspnoea, cyanosis, and cough, with expectoration from associated 
bronchitis. There is no fever. The dyspnoea is in proportion to the 
degree of emphysema, and is aggravated by the coexistence of bron- 
chitis, asthma, and eccentric hypertrophy of the right ventricle, which 
are very frequent complications in cases of long standing. When 
the degree of emphysema is only moderate, dyspnoea is not complained 
of except upon climbing or walking briskly, or after a hearty meal. 
But when the degree of emphysema is great, dyspnoea is constant ; it 
interferes with all exertion, frequently necessitates orthopnoea, and 
prevents continuous speech, so that patients speak in broken sentences 
or syllables. 

( [i/anosis is marked. The livid lip is common in the asylums for 
old men. The face is of a dingy pale color, but becomes bluish on 
exertion. The extremities are also dusky, and the blueness is general 



PLATE XXII. 

FIG. 1. — Anterior Aspect. 




FIG. 2. — Posterior Aspect. 




Emphyzema. 

Hyperresonance. Enlargement of lungs and diminished respiratory movement 
of margins. Diminished fremitus. Signs of bronchitis. 



DISEASES OF THE LUNGS AND PLEURM. 565 

in severe cases. This cyanosis, the round shoulders, and the drawn, 
chronically anxious expression, if I may so term it, make it easy to 
pick out the emphysematous subjects in a ward of chronic cases. 

Respiration is not accelerated, and may be diminished in frequency. 
It is often accompanied by wheezing when chronic bronchitis coexists. 

The cough varies greatly in frequency ; it may be altogether absent, 
since its presence simply indicates an associated bronchitis. This bron- 
chitis may for years be present only in the winter. In children it may 
be associated with asthma. It may arise on changes of the weather ; 
finally it becomes chronic. The expectoration is that of chronic bron- 
chitis (q. v.). It is rarely stained with blood. 

Physical Signs. (Plate XXII. ). The physical signs of emphysema 
depend upon its degree and upon whether it is complicated with 
chronic bronchitis or not. 

Inspection: In well-marked cases the chest is barrel-shaped (see 
under Inspection). There is little movement of the chest in respi- 
ration, because the lung is already in a condition of full inspiration 
(expiratory dyspnoea). Vocal fremitus and resonance are usually dimin- 
ished. Percussion : The percussion-note is abnormally clear, and may 
even be tympanitic. Hyper-resonance is typical of the disease. When the 
distention is extreme the note may be woodeny. The lungs are enlarged. 
The heart-dulness becomes obliterated by the overlapping lung. The 
upper margin of the liver falls one or two interspaces below the normal. 
The resonance extends higher above the clavicles than normal. 

On auscultation the inspiration is found to be distant and feebler 
than normal, while the expiration is prolonged, and may become three 
or four times the length of the inspiration. Grazing or rubbing 
sounds have been described and attributed to the friction of distended 
vesicles against the pleura. Other adventitious sounds are due to an 
associated bronchitis, pleurisy, or tuberculosis. But bronchitis is such 
a common accompaniment of emphysema that the rales of the former 
become almost symptomatic of the latter. Their character in emphy- 
sema does not differ from that in chronic bronchitis (q. v.). 

The Heart. The apex-beat is absent. There is epigastric pulsation 
or systolic shock. The normal area of heart-dulness is encroached 
upon by the distended lung, and the heart itself is pushed to the right, 
the apex-beat being frequently at the xiphoid cartilage. If the em- 
physema attain a very high degree, there may be no perceptible dulness, 
except on very strong percussion over the cardiac region. The heart- 
sounds appear feebler and more distant than normal. The right ven- 
tricle becomes dilated and hypertrophied, as the result of the pulmo- 
nary congestion produced by emphysema. The pulmonary second 
sound is accentuated. A tricuspid regurgitant murmur may be heard. 
Venous congestions are common in the later stages. Albuminuria is 
common. (Edema of the feet and limbs may occur, but general ana- 
sarca is rare. 

The general health suffers by loss of strength and capacity for 
physical and mental work, rather than by loss of flesh. The patients 
are large-chested, stoop-shouldered, and short-breathed, and have an 
anxious expression of countenance. 



566 SPECIAL DIAGNOSIS. 

Diagnosis. This is based upon the history (heredity, occupation, 
long duration), the occurrence of dyspnoea and cyanosis, and of winter 
cough or chronic bronchitis, and upon the physical signs. 

Emphysema can be distinguished from pleural effusion and from 
aneurism, which may cause dyspnoea, by the universal hyper-resonance 
on percussion. Pleural effusion, which also causes bulging, is usually 
unilateral, and the percussion-note is flat. The area of dulness of the 
heart and aorta is diminished in emphysema. 

Pneumothorax, which most resembles emphysema in its physical 
signs, develops suddenly, affects one side, and has a hollow, tympan- 
itic note on percussion. The succussion-splash, metallic tinkling, and 
coin-test have no counterpart in emphysema ; moreover, the antecedent 
history and mode of development are different. 

Atrophic emphysema is due to the degeneration of age. The lung is 
reduced in size. The diameters of the chest are lessened. The ribs 
are oblique. There is atrophy of the chest-muscles. The patients 
have dyspnoea. There are other signs of senility. 

In interlobular emphysema the physical signs are the same as those 
of vesicular emphysema, but it develops suddenly and is liable to be 
followed by emphysema (intercellular) of the neck, which on palpation 
gives a peculiar crepitation. The friction-sound and crackling which 
have been described as occasional adventitious sounds in vesicular 
emphysema are more commonly heard in the interlobular form. 

It is caused by rupture of the air-cells, and hence occurs in diseases 
in which a great strain is put upon them — especially, therefore, in 
whooping-cough, but also occasionally in pulmonary hemorrhage and 
pneumonia ; violent coughing and laughing, and great straining, as in 
child-labor, are capable of producing it. 

Bronchiectasis. Dilatation of the bronchi occurs secondarily to 
affections which tend to weaken the walls of the tubes and to lessen 
their elasticity. Hence, it is found in chronic bronchitis with emphy- 
sema, in chronic phthisis, in catarrhal pneumonia in children, in 
chronic obstruction from external pressure or foreign bodies. (See Ob- 
structions.) It also occurs when the lungs contract in fibroid pneu- 
monia, or in pleural thickening. It occurs in two principal forms : 
the simple, in which the affected tubes are uniformly dilated ; and the 
saccular, in which larger or smaller pouches are formed. It is com- 
moner in males than in females, and probably begins most frequently 
in adult or middle life. One lung only is affected in about one-half 
the cases, and when both lungs are affected (chronic bronchitis and 
emphysema) it is not often to the same degree. 

The subjective symptoms consist of cough, expectoration, and a 
variable amount of dyspnoea. Eventually there may be some loss of 
flesh and strength. 

The cough is usually paroxysmal. It may occur only in the morn- 
ing after the dilated tube fills. It may follow change in position. A 
paroxysm is followed by copious expectoration, sometimes amounting 
to a pint and a half in twenty-four hours. It is grayish-brown and 
mucopurulent, faintly or extremely fetid. The sputa contain mucus, 
pus, fasts of the tubules, and various salts. Charcot-Levden and fattv 



PLATE XXIII. 



FIG. 1.— Anterior A 



spect. 




Stf& 









FIG. 2. — Posterior Aspe< 




Bronchiectasis. 

Chronic pleurisy with induration of the right lower lobe and bronchiecta. 
Vicarious emphyzema of the left lung. Bronchitis. 



DISEASES OF THE LUNGS AND PLEURAE. 567 

crystals, vibrios, leptothrix, and bacteria (Fox) can be found on micro- 
scopical examination. Elastic fibres are found only if the tubes are 
ulcerated. In a conical glass the sputum separates into three layers — 
a frothy brown top, a thin mucoid layer in the middle, and a granular 
layer below. Hemorrhage is rare, but may occur even when tubercu- 
losis is absent. 

Dyspnoea is not usually severe, except when the dilatation is compli- 
cated by disease of the heart or lungs, or during an acute attack of 
bronchitis. 

Physical Signs.. (Plate XXIII.) The physical signs differ according 
to the extent and variety of the dilatation. In simple dilatation there 
may be nothing different from the signs found in chronic bronchitis, 
except a tendency to more bronchial respiration, with rales having a 
metallic quality. Percussion will vary according to the degree of altera- 
tion of the lung-tissue surrounding the affected bronchi, and according 
to the extent of the dilatation and its proximity to the surface. In the 
simple forms the percussion-note, if altered, is somewhat less resonant 
and higher in pitch, whereas in saccular dilatations, favorably situated 
for percussion, the note is tympanitic if the pouch is empty. On aus- 
cultation in simple dilatation the breathing approaches the bronchial, 
and is accompanied by bronchial rales. In saccular dilatation the 
sounds are practically those of a cavity, respiration varying from bron- 
chial to amphoric. Vocal resonance and tactile fremitus are usually 
both increased, but the latter may be diminished. 

Diagnosis. The diagnosis of simple dilatation from chronic bron- 
chitis may be impossible, but copious and fetid expectoration indicates 
the former. The diagnosis of the saccular form from tuberculosis of 
the lung with cavity is difficult. Wilson Fox says the severe cases 
are usually associated with consolidation of the lung or with tubercle ; 
but even without the presence of the latter they often present phthisi- 
cal symptoms — retraction of the chest, with the physical signs of exca- 
vation, pains in the side, haemoptysis, pyrexia, nocturnal perspiration, 
and diarrhoea — which may all coexist with only an induration of the 
lung and dilatation of the bronchi. The diagnosis must be made by 
noting the persistency of the physical signs, which change but little 
and are not progressive as are those of tuberculosis ; the protracted 
course of the disease ; the character of the sputum ; and the compara- 
tively slight impairment of the general health. 

The Morbid Growths. 

Cancer and Other New Growths of the Lung. The new growths 
may be primary or secondary. The latter are most common. Of 
primary cancer, the epithelioma is most common ; encephaloid and 
scirrhus come next. Sarcoma is sometimes primary. Secondary new 
growths succeed disease in the abdominal organs, the genito-urinary 
tract, the bones, the breast, and the eye. 

Symptoms. The general symptoms of malignant growths accom- 
pany the thoracic symptoms. Chest-pain, dyspnoea, cough, and a 
peculiar expectoration belong to the latter. The pain is due to asso- 



568 SPECIAL DIAGNOSIS. 

ciate pleurisy ; the dyspnoea is paroxysmal. (See Dyspnoea from Press- 
ure on Bronchi.) The expectoration is dark, like prune-juice. Signs 
of intrathoracic pressure are seen. The external thoracic veins are 
enlarged. The face and arms may be cyanosed, or one arm only may 
be affected. The heart may be dislocated, the trachea changed in its 
course ; compression of trachea and bronchus causes dyspnoea. 

Physical Signs. In primary cancer the affection is unilateral ; in 
secondary forms, bilateral. The physical signs are those of pleural 
effusion or of local consolidation. The consolidation may be massive 
and not partake of the shape of a lobe. Often signs of effusion and 
consolidation are combined (enlargement, immobility, absent fremitus, 
but bronchial breathing). In the secondary forms the disease is bilat- 
eral. The signs are mixed. They indicate diminished air in the lung 
structure. Care must be taken not to overlook the pleural effusion 
which accompanies the process, the removal of which gives temporary 
relief. In both forms external lymphatic glands, particularly the 
cervical, may be enlarged. 

Diagnosis. The diagnosis is based upon : (1) The age (after forty) ; 
(2) the occurrence of emaciation ; (3) the duration of the disease, often 
rapid, rarely beyond eight months ; (4) the presence of primary disease 
elsewhere ; (5) the presence of moderate fever ; (6) the signs of intra- 
thoracic pressure ; (7) the involvement of lymphatic glands ; (8) the 
occurrence of irregular areas of consolidation and of pleural effusion, 
alone or combined ; (9) the characteristic expectoration ; (10) dyspnoea 
due to pressure on the bronchus or trachea ; (11) the absence of bacilli 
from the sputum. 

An effusion can often be recognized only after puncture. Hemo- 
thorax is not necessarily present. 

Gross Parasites. 

Hydatid Disease of the Lungs. The lungs are affected hi about 
1 1 per cent, of the cases of hydatid disease. The symptoms, according 
to Wilson Fox, consist of dyspnoea, pain hi the chest, cough, occasional 
haemoptysis, and sometimes the expectoration of hydatids, the sputa 
being otherwise bronchitic, or presenting the characteristics of pneu- 
monia or gangrene when these complications are present. Gradually 
weakness increases, sometimes with pyrexia, which, when combined 
with emaciation, may impart to the case a considerable resemblance to 
phthisis ; pressure-symptoms occasionally occur, and the physical signs 
are either of consolidation of the lung or of pleural effusion, together 
with certain peculiarities depending on the size and site of the tumor. 
Graham states that they are more frequent in the right lung and more 
common at the base, causing marked bulging of the thoracic wall. 
When the physical signs are those of pleural effusion, localization of 
the fluid to a definite area takes place, and hence is not related to the 
shape of the pleural cavity. The breathing may be tubular ; there is 
condensed lung between the hydatid and the thoracic wall. The symp- 
toms present — cough, dyspnoea, anaemia, emaciation, and clubbing of 
fingers — too often lead to the diagnosis of phthisis. Haemoptysis 



DISEASES OF THE LUNGS AND PLEURA. 569 

occurs in many cases. The temperature is normal — an important 
point in diagnosis. If the cyst ruptures, the sputum is diagnostic. 
Complications often mask the diagnosis. It must be distinguished 
from pleurisy, localized empyema, pulmonary abscess, phthisis, actino- 
mycosis, and mediastinal tumors. 

Diseases of the Pleura. 

The large lymph-structures which cover the lung and line the inside 
of the thorax are often the seat of disease. It is usually of an inflamma- 
tory nature. Hence, pleurisy, or pleuritis, is the most common affec- 
tion of the pleura. It may be, as to distribution, bilateral or unilateral ; 
as to extent, local or general ; as to the nature of the inflammation, 
plastic, serous, or purulent. The inflammation may be acute or chronic. 
It is rarely primary. It arises in the course of general disease, or is 
the result of the extension of inflammation, chiefly of an infectious 
nature, from neighboring structures. 

1. Disease of the ribs or vertebrae, diseases of the mediastinum, of 
the aorta, oesophagus, and especially of the lung, give rise to various 
forms of pleurisy, depending upon the nature of the primary affection. 

2. Diseases below the diaphragm. Abscess of the liver ; perfora- 
tive inflammation of other viscera adjacent to the diaphragm ; abscess 
of the spleen or pancreas ; pus in the pelvis or about the appendix, 
may give rise to purulent pleurisy by the pus burrowing upward or 
by infection through the lymph-channels. 

3. Disease of the lungs. In the large majority of cases pleurisy in 
some form occurs in the course of pulmonary disease. In all surface 
inflammations of the lungs there is associate pleurisy. It is seen in 
pneumonia, in tuberculosis, in gangrene, and in abscess. 

Pleurisy may be simple or purulent. Empyema is always due to 
infection from the exterior, as the ribs ; from the lungs (pneumonia) ; 
suppuration below the diaphragm ; or to general infective processes, 
as septicaemia, pyaemia, and tuberculosis. 

The general diseases in the course of which pleuritis arises are 
usually infective, or of such nature as to cause irritating products to 
circulate in the blood. Of the former, the most common is tuberculo- 
sis ; the next most common are septicaemia and scarlatina ; while to the 
latter class belong Bright' s disease, gout, diabetes, rheumatism, and 
scurvy. Purulent pleurisy is more common in children than in adults ; 
in males than in females ; and more common in tuberculous pleurisy 
and pyaemia than in rheumatism and Bright' s disease. 

Acute Pleurisy. Acute pleurisy may be primary, or may be sec- 
ondary to disease of the lung, or be part of a general infection. Three 
stages in the morbid processes usually occur, although it may be 
arrested in the first stage. 

Symptoms of the First Stage. Dry Pleurisy. The onset of the dis- 
ease is usually abrupt, and is marked by fever, Avhich may or may not 
be preceded by chill, and is followed by pain in the side, dyspnoea, 
and cough. The pain is sharp, stabbing, or tearing in character, and 
is usually, but not always, referred to the seat of pleurisy. This is 



570 SPECIAL DIAGNOSIS. 

most frequently on a level with the nipple, or a little below this, and 
more often anteriorly or in the axilla than posteriorly. The pain is 
caused by the rubbing together of the inflamed surfaces of the pleura, 
and hence is excited by respiration and cough. For this reason the 
patient is inclined to restrict the motion of the affected side as much 
as possible ; he does this by leaning over toward that side and by 
pressing his elbow in against the chest-wall. Pain is usually the first 
symptom noticed by the patient. The cough is dry and painful. 
Fever is moderate. 

Physical Signs. The physical signs in primary cases are a friction- 
sound heard on inspiration and expiration. This friction-sound may 
be a nest of fine, dry, crepitant rales, which are very superficial, and 
appear to be just under the ear ; or a coarse rubbing sound, heard over 
a larger surface, and resembling a bronchial rhoncus, from which it can 
be distinguished by its persistence after the patient has coughed. The 
lungs themselves present nothing abnormal. 

If the inflamed surfaces become glued together by plastic lymph, 
recovery usually occurs very soon, though pain often persists for a 
long time in lessened degree, and the pleurisy is liable to be re- 
lighted. 

Symptoms of Second Stage, or Stage of Effusion. If effusion takes 
place, the two layers of the pleura become separated ; hence, pain and 
friction-sound cease, and physical exploration shows that a collection 
of fluid intervenes between the chest-wall and the lung. 

The physical signs (Plates XXIV. and XXV.) of this stage are 
(1) enlargement of the affected side, increase in semi-circumference, 
with fulness of interspaces ; (2) diminution of movement ; (3) absence 
of vocal fremitus and resonance ; (4) dulness or flatness (deadness) on 
percussion, with great increase in the resistance to the pleximeter 
finger ; (5) absent or greatly diminished respiratory murmur ; (6) dis- 
placement of organs. 

The dead percussion-note being caused by fluid, it follows that its 
upper level will change with the position of the patient if the fluid is 
free. If the upper level is at the third interspace when the patient is 
sitting up, it will fall to the fourth or lower when he is lying down. 
This change of level cannot be appreciated when the effusion is very 
large. Moreover, above the line of dulness the percussion-note is hyper- 
resonant or tympanitic — Skoda' s resonance. Toward the spine on the 
affected side there may be partial resonance and bronchial breathing, 
because here the lung is compressed against the vertebrae. In large 
effusions the tympanitic resonance in the second interspace does not 
change when the mouth is opened — that is, " Williams' tracheal tone " 
can often be elicited. The upper limit of dulness in large pleural 
effusions is higher at the spine and slopes downward, and is lowest in 
front. This parabolic line is only obtained when the patient is in the 
erect posture. In moderate effusions the line of dulness is lowest near 
the spinal column, rises in the middle of the scapula and slopes down- 
ward, assuming the shape of the letter S as it passes toward the front 
(Garland). The patient should take deep breaths before the percus- 
sion is performed. At the left base in front the semilunar space is 



PLATE XXIV. 




B 







FIG. 2. — Posterior Aspect. 







Pleurisy with Effusion (right-sided). 



PLATE XXV. 



FIG. 1. — Anterior Aspect. 




M/fv 



FIG. 2. — Posterior Aspect. 










v.- 




Pleurisy with Effusion (left-sided). 



DISEASES OF THE LUNGS AND PLEURAE. 



571 



obliterated, dulness continuing to the margin of the ribs. In small 
effusions the dulness may be limited by the posterior axillary line, 
resonance being present in the lateral and anterior regions. 

On auscultation below the upper level of the effusion posteriorly the 
voice frequently has a metallic quality resembling the bleating of a 
g 0a t — cegophony. It occurs usually when the effusion is moderate, 
and may be heard only over a limited area. It is commonly heard at 
or above the angle of the scapula. Bronchophony may be heard when 
tubular breathing is present. 

While the respiratory murmur is, as a rule, absent, breath-sounds 
may be heard, and are then weak and distant, or bronchial. In such 
cases there may or may not be adhesions. Bronchial breathing may 
be present along the spine in small effusions, and in large effusions in 
the interscapular region. Bronchial breathing, tubular in character, 
is said to be almost constant in children. It may also occur when 
pneumonia coexists. In one of the cases in my ward the signs were 
like those of a large cavity at the right base, but the immobility, the 
absent fremitus, the enlargement, and the exploratory puncture dis- 
proved its presence. 

At the level of the fluid a friction-sound may persist. Above the 
level of fluid anteriorly the breath-sound may be bronchial or broncho- 
vesicular, associated sometimes with fine rales, due to compression and 
slight oedema. 



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Displacement of Organs. If the effusion is on the left side, the 
mediastinum and heart become displaced to the right, and the apex- 
beat may be found in the epigastrium, or even to the right of it. The 
occurrence of displacement of the heart must also be judged by the 
position of maximum intensity of the heart-sounds, as the heart may 
be behind the sternum. At the same time the semilunar space (Traube's 
line) is lower than usual or entirely effaced. On the left side inaction 
of the diaphragm may be observed, and the tissues at the costal margin 
fall in with each inspiration. If the effusion is on the right side, the 



572 • SPECIAL DIAGNOSIS. 

diaphragm, and with it the liver, is depressed, and the mediastinal 
contents are moved to the left. 

The subjective symptoms during this stage are slight or moderate 
fever, sometimes intermittent in character, with recurring chills ; con- 
siderable dyspnoea, occasionally amounting to orthopnoea when the 
effusion is very extensive ; and dry cough, which adds greatly to the 
dyspnoea. There is frequently some evidence of insufficient oxygena- 
tion of the blood ; when this amounts to cyanosis, the condition is one 
of great danger. The urine presents changes in amount. In ad- 
vancing effusion the amount lessens very much ; it increases in amount 
with the decline of the fluid. Pleurisy may be complicated with bron- 
chitis, pneumonia, and pericarditis. 

Empyema. The above-mentioned physical signs apply chiefly to 
serous effusions. They are also present in effusions of pus. Other 
physical phenomena, however, and different general symptoms distin- 
guish the two kinds of effusions, although it must be confessed that 
aspiration must often be resorted to before a positive diagnosis can be 
made. 

Physical Signs. The physical signs of empyema are the same as 
those of other effusions within the pleura. In addition, especially in 
children, local oedema of the chest-wall may be found. Another sign 
was pointed out by Bacelli, and is held by others to be of diagnostic 
significance. In purulent effusions the fremitus produced by the whis- 
pering voice is not transmitted to the hand laid over the effusion, 
whereas in serous effusions such vibrations are transmitted. In locu- 
lated empyema the diagnosis is very difficult. In one of my cases 
dulness continuous with that of the heart extended to the second rib 
and laterally to the post-axillary line. The dulness occupied three 
interspaces. Additional physical signs were immobility, prominence 
of interspaces, localized above the heart, absent fremitus and resonance. 
There were no breath-sounds, but an abundance of rales, apparently 
very superficial. The rales complicated the physical signs. Martin 
operated for me and removed two ounces of pus from a small abscess 
above the heart and between the lobes. 

In empyema a local area may become more prominent and the sur- 
face assume an inflammatory appearance. It is an indication of dis- 
charge of the abscess through the chest-wall. It is usually found in 
the fifth interspace in front, or below the angle of the scapula behind 
— empyema necessitatis. (For a microscopical and chemical description 
of the " Effusion within the Pleural Sac," and of the morphological 
elements of the purulent effusions, see Chapter XXL, Part I.) 

General Symptoms. The general symptoms are more marked in 
empyema than in simple serous effusion. The temperature is higher 
from the onset. It soon becomes intermittent or remittent. Chills 
or chilliness may attend the beginning of each febrile paroxysm, and 
sweats occur with the daily fall of temperature, or at irregular periods 
during the twenty-four hours. The heart's action is more rapid and 
the pulse more feeble, soon becoming dicrotic. Examination of the 
urine may aid in the distinction of the two forms of the effusion. 
Albumosuria occurs in purulent pleurisy. It must be remembered 



DISEASES OF THE LUNGS AND PLEURJE. 



573 



that albumosuria occurs in suppuration from other causes. Thus, in 
phthisis with suppuration of a cavity pleural effusion may develop. 
The albumosuria that attends the primary process must not be mis- 
taken for that which occurs in empyema. Indican is also present in 
excess in the urine in suppurations. Before a decisive conclusion is 
arrived at two or more examinations of the urine should be made. 
Examination of the blood may aid in arriving at a conclusion. In 
purulent effusion there is usually leucocytosis. 

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Empyema following pneumonia. (Fever absent from seventh to fourteenth day.) 

Notwithstanding the positive physical signs of effusion the character 
of the effusion may not be recognized until perforation into the bron- 
chus has taken place. The peculiar character of the expectoration that 
attends this accident is described in the section on Sputum. 

Hydrothorax. This is an accumulation resulting from a transuda- 
tion. (For character of the fluid, see Chapter XXL, Part I.) It 
occurs in the course of diseases which produce anasarca, as failing 
organic heart disease, chronic Bright' s disease, and debilitating diseases, 
as scurvy. Locally, it may attend carcinoma of the pleura or obstruc- 
tive disease of vessels within the mediastinum. 

The physical signs of hydrothorax are those of effusion in acute 
pleurisy. The general symptoms belong to the primary disorder. 
Dyspnoea may develop gradually and even amount to orthopnoea. 
It is distinguished from inflammatory effusions by the character of the 
fluid, by the absence of the general symptoms of inflammation, by its 
insidious development, and by its bilateral distribution. 

Hemothorax. The transudation of blood into the cavity of the 
pleura occurs rarely from the rupture of an aneurism into the sac. 
The fluid is then pure blood. Serous effusions in which a large amount 
of blood is found point to primary carcinoma of the pleura, or to tuber- 
culous disease. Both specific processes of this serous membrane may 
occur, however, without the transudation of sero-bloody fluid. 

Thickened Pleura. Chronic inflammation, with thickening of the 



574 SPECIAL DIAGNOSIS. 

pleura from excessive development of connective tissue, occurs in 
tuberculosis and in cases of combined pleuritis and peritonitis. The 
thickening of the pleura is usually more marked at the base. 

The physical signs (Plate XX VI.) are pronounced, and are those 
of effusion, but without enlargement of the chest. There are marked 
contraction and diminution in movement of the affected side. The 
fremitus is absent. There is dulness on percussion, or even flatness. 
The breath-sounds are distant or are absent. Along the vertebrae, 
especially opposite the angle of the scapula, bronchial breathing may 
be heard. The subjective symptoms of cough and dyspnoea are pres- 
ent. The degree of cough depends upon the condition of the lung. 
If there is bronchitis or tuberculosis, the cough is excessive. The 
amount of dyspnoea depends upon the degree of compression of the 
lung by the thickened pleura. 

Tuberculous Pleurisy. 1 The affection may be acute or chronic. 
It may occur primarily, be a part of general tuberculous infection, or 
occur secondarily to disease of the lungs: It may give rise to all forms 
of the inflammatory process : First, dry pleurisy ; second, pleurisy 
with effusion ; third, pleurisy with great thickening. Often the dis- 
tinction between tuberculous pleurisy and pleurisy due to other causes 
cannot be determined positively. If it is associated with tuberculosis 
in other organs, or the patient is of tuberculous habit and exposed to 
infection, or if there has been a history of previous tuberculosis, the 
pleuritic infection is probably of tuberculous origin. If the affection 
is bilateral and associated with peritoneal inflammation, and at the 
same time no other cause exists for serous membrane inflammation, 
the probability of its tuberculous origin is very strong. 

Pulsating Pleural Effusion. Wilson has made the most recent 
studies of this rare affection. The effusion within the pleura pulsates 
synchronously with the ventricular- systole ; the pulsation is detected 
usually by inspection and palpation. In some instances its presence 
is only determined by palpation. It may be confined to two or three 
interspaces, or occupy the anterior aspect of the thorax and the axil- 
lary region on the left side. Rarely the pulsation is behind. It is 
usually situated on the left side. The original effusion is purulent in 
the large majority of cases. The physical signs and general symptoms 
of empyema are present. Nevertheless, the disease simulates aneurism 
of the aorta. The latter affection, however, is accompanied by vascu- 
lar symptoms and physical signs in the course of the aorta. Pulsating 
empyema is distinct in movement from the pulsation of the aorta and 
occupies a different anatomical site. 

Diaphragmatic Pleurisy. In diaphragmatic pleurisy there is in- 
tense pain in the epigastrium. Gueneau de Mussy 2 regards a pain 
along the tenth rib, extending from the anterior extremity to the 
sternum and xiphoid cartilage, as pathognomonic. Other symptoms 
are nausea, vomiting, and hiccough. The dyspnoea often amounts to 
orthopnoea, or the patient sits stooping forward. The anxiety of the 

1 See " Notes on Tuberculous Pleurisy." Musser, American Climatological Associa- 
tion, 1893. 

2 Arch. gen. de Med., 1853, vol. xi. Quoted by Fox. 



PLATE XXVI 





Fibroid Phthisis with Chronic Pleurisy. 

Heart drawn toward the right and aorta uncovered by retraction of lung 
margin. Vicarious emphyzema of left lung. 



DISEASES OE THE LUNGS AND PLEURAE. 575 

patient is very great. The fever is usually higher than in ordinary 
pleurisy, and there may be delirium. Effusion may lessen the pain. 
Peritonitis may occur at the same time, or be secondary to the pleurisy. 

Diagnostic Features. The special features of diagnostic impor- 
tance that are observed in the course of pleurisy are the pain, the 
dyspnoea, the cough, the fever, the physical signs of effusion within 
the pleura, and the results of exploratory puncture. Pain : The pain 
is short, sharp, lancinating, and is usually recognized quite readily by 
its character and location. It must be distinguished from the pain 
due to pleurodynia and intercostal neuralgia. The pain of pleurisy is 
associated with cough and is increased by breathing. It causes dimi- 
nution of movement of the affected side. The patient is compelled to 
sit up in bed, or lie on the side which is the seat of pain. Cough : In 
the first stage the cough is short, suppressed, dry, and painful. It is 
constant. In the second stage it changes in character. There is no 
pain, there is no expectoration. It is frequent and irritating, and of 
a peculiar sound which is difficult to describe, and yet, when once 
heard, is most suggestive in subsequent cases. It is short and lacks 
resonant quality, as if the fluid in the chest stopped the sound-waves. 
Dyspnoea in the first stage is due to pain, in the second stage to the 
large effusion which encroaches upon the normal air-space. It is not 
diagnostic. The physical signs of pleural effusion have been frequently 
reiterated. The most decisive are diminution or absence of move- 
ment, enlargement of the affected side, absence of fremitus, flatness on 
percussion, fulness of intercostal spaces, and the displacement of organs. 
The latter is of the greatest diagnostic importance in the distinction 
between consolidation and effusions. The results of exploratory punc- 
ture lead to decisive conclusions usually, although it must not be for- 
gotten that effusions may be loculated and therefore missed by the 
aspirating-needle. Or the enormously thickened pleura may intervene 
between the exudation and the surface of the chest, and prevent with- 
drawal of the fluid. Finally, effusions may complicate inflammatory 
processes, as pneumonia, tuberculosis, or abscess of the lung. Securing 
fluid for diagnosis by aspiration, therefore, does not necessarily exclude 
these conditions, and hence, before the process is decided to be within 
the pleura alone, the sputum and other conditions must be taken into 
consideration. 

Differential Diagnosis. Acute plastic pleurisy is diagnosticated from 
acute pneumonia by the friction-sound and the maintenance of the clear 
percussion-note and normal respiratory murmur, with unaltered vocal 
resonance and fremitus. When effusion takes place the chest is en- 
larged and immobile, especially on the affected side ; the interspaces 
are filled out and the diaphragm is depressed ; these changes do not 
occur in pneumonia. Moreover, the percassion-note in pleural effusion 
is flat, with greatly increased resistance ; the shape of the upper line 
of dulness is diagnostic ; the respiratory murmur is feeble and distant, 
or entirely absent, except along the spine, where the compressed lung 
yields bronchial breathing, and also above the line of effusion, where 
the lung yields exaggerated breathing. In pneumonia, on the other 
hand, the percussion-note is dull, without greatly increased resistance, 



576 SPECIAL DIAGNOSIS. 

and the breath-sounds are bronchial. In addition, in pleurisy, the 
vocal resonance and fremitus are usually almost if not entirely absent, 
and posteriorly at the level of the effusion segophony may be detected. 
In pneumonia, on the contrary, vocal resonance and fremitus are 
increased in intensity. In pleurisy with effusion the movable organs 
are dislocated and Traube's line is obliterated. 

Finally, the fever of pneumonia is much higher and more continu- 
ous than that of pleurisy, the respirations more frequent, the cough 
looser, and in typical cases followed by rusty sputa. (Compare the 
temperature chart in article on Pneumonia.) A crucial test is aspiration 
with a hypodermic needle ; in pleural effusion, serum is withdrawn ; 
in pneumonia, a few drops of thick blood. 

In pleurodynia there is also severe pain in one side ; but the pain is 
more continuous than that of pleurisy, and consists of a constant aching 
or a burning sensation. It is made worse by twisting or turning, as 
well as by breathing. The side is also tender to the touch. The pain 
is not so sharply localized as that of pleurisy, and may leave one side 
and affect the other. It is unaccompanied by fever or friction-sound, 
and is frequently found in rheumatic subjects. 

In intercostal neuralgia there is the same absence of fever and fric- 
tion-sound. The pain, however, is sharply localized, as in pleurisy, 
but is of the darting, neuralgic character, and is associated with tender- 
ness at the points of exit of the intercostal nerves. It is most common 
in women, especially if they have uterine disturbances. It is more 
frequent on the left side, and just beneath the mammary gland. 

Chronic Pleurisy. Chronic dry, or plastic, pleurisy is the result of 
an acute attack, or develops insidiously if tuberculous. It causes 
great deformity of the chest from contraction, and compensatory 
emphysema of the healthy lung. The heart is dislocated or cannot 
be found on physical examination, because it is overlapped by lung or 
is drawn behind the sternum. There is considerable spinal curvature, 
dislocation of the scapula, deformity of the shoulder, and indrawing 
and overlapping of the ribs at the base of the chest. 

Chronic pleurisy with effusion results from an acute attack of pleurisy, 
in which the fluid remains unabsorbed, or from subsequent attacks. 
The physical signs are the same as in acute effusion. So far as subjec- 
tive symptoms go it may remain latent ; patients so affected not infre- 
quently go about their work with comparatively little dyspnoea. There 
may be an evening rise of temperature and acceleration of the pulse. 
Chronic effusions are more likely to be purulent in children than in 
adults. When empyema results, the fever becomes hectic ; there are 
chills and sweats, pysemia develops, and death is likely to occur from 
some intercurrent suppuration, as cerebral abscess. 

After chronic effusion the chest is rarely restored to its original shape, 
even if the effusion is finally absorbed. The affected side becomes 
motionless and retracted. In process of time the spme may be bent. 
The opposite lung becomes hypertrophied. The patient is usually in 
precarious health, liable to acute attacks of pain in the affected side, 
and liable also to be carried off by phthisis or some intercurrent affec- 
tion. Rarely the patient may maintain good health ; complete cure 



PLATE XXVII. 



FIG. 1.— Anterior Aspect. 




W t 



FIG. 2.— Posterior Aspect. 




ff^' 



\V 



Pneumothorax (left-sided). 



DISEASES OF THE LUNGS AND PLEURA. 577 

is even possible, with restoration of the retracted side to, or almost to, 
normal dimensions, especially in children. 

Pneumothorax. Pneumothorax consists in an accumulation of air 
in the pleural cavity, accompanied or followed by an outpouring of 
fluid, which may be serous or purulent, constituting respectively hydro- 
pneumothorax and pyo-pneumothorax. 

Pneumothorax may originate : 1. In causes external to the chest, 
by perforation of the chest-wall and pleura. 2. In perforation of the 
lungs, bronchi, or oesophagus. 3. It may be caused by gases devel- 
oped from an existing effusion. 

The most frequent cause is tuberculous disease of the lung, and next 
an empyema ; out of 121 cases collected by Saussier, 81 were due to 
phthisis and 29 to empyema. It may occur very early in tuberculosis 
of the lung, and may even be the first symptom of that disease. 
(See cases referred to by Fox and recorded by Louis and Chomel). 
The left side is affected not quite twice as often as the right ; the 
disease is usually unilateral. The onset of the condition is usually 
sudden. During a paroxysm of coughing or vomiting, or without 
immediate cause, there is an escape of air into the pleura, and in the 
majority of cases the patient at once complains of acute pain in the 
chest and excessive dyspnoea with great dread of impending suffoca- 
tion. The patient often sinks into collapse from shock, but sudden 
death is rare. If the escape of air into the pleura is gradual, there 
will be less pain and dyspnoea. 

Physical Signs. (Plate XXVII.) The chest is distended, especially 
on the affected side ; the percussion-note is a bell-like tympany except 
when the distention is excessive and the air contained is under great 
tension, when the note is proportionately duller and higher in pitch; the 
diaphragm is depressed and the heart displaced, unless adhesions pre- 
vent it. In left pneumothorax it may beat on the right side, the whole 
mediastinum being pushed to the right ; in right pneumothorax the 
mediastinum may be pushed to the left nipple ; hence there is reso- 
nance over the normal cardiac region. The pitch of the percussion- 
note may be raised when the mouth is closed, and lowered when it is 
open (Wintrich's change of note), and a cracked-pot sound can be 
elicited in some cases, but this occurs only when the communication 
with the pleura remains open. 

A valuable sign of pneumothorax is the coin-test, or, as Trousseau 
named it, the Bruit d'airain. A silver coin is laid upon the chest and 
struck with another, while the auscultator applies the stethoscope oppo- 
site to the point struck, or over any part of the side distended by air. 
The ringing coin-sound is reproduced with great intensity. It is path- 
ognomonic, and the outlines of the cavity can be traced by it. 

When fluid is present, as it usually is, there will be the ordinary 
signs of a pleural effusion, which have been sufficiently dwelt upon. 
The fluid is more mobile in pneumothorax, however, than in simple 
pleurisy, so that its level changes more quickly with change of posture 
of the patient, and Hippocratic succussion is readily obtained. This 
movable dulness is a very valuable sign — indeed, almost pathognomonic. 

As the lung is compressed against the spine by the air, as it is by 

37 



578 SPECIAL DIAGNOSIS. 

the fluid in pleurisy, the breath sounds are feeble or absent, except 
over the root of the lung, where the breathing is bronchial. But if 
the lung is not completely collapsed, amphoric breathing may be heard, 
the air-chamber of the pleura acting as a consonance-box ; it may be 
heard with both inspiration and expiration, or only with expiration. 

Metallic tinkling is a sound believed to be due to the vibration of 
bubbling bronchial rales re-echoed through the air-chamber, or to 
drops of fluid falling from above upon the surface of the effusion. Re- 
echoing, with metallic quality, may also accompany the heart-sounds, 
and in cases in which the respiratory murmur is amphoric the vocal 
resonance is of the same character. Vocal fremitus is generally 
absent. 

Differential Diagnosis. Pneumothorax is most likely to be 
confounded with (1) emphysema ; (2) tuberculosis of the lungs with 
large cavities ; (3) cases of pleural effusion in which above the upper 
level of the fluid the lung is markedly hyper-resonant ; and (4) abscess 
below the diaphragm containing air (pyo-pneumothorax subphrenicus). 

1. Emphysema can be distinguished by its slow onset, its relatively 
slight impairment of the general health, by the fact that it is bilateral, 
whereas pneumothorax is almost always unilateral, and by the exist- 
ence of feeble breathing with greatly prolonged expiration. Amphoric 
breathing and resonance, metallic tinkling, and signs of fluid are all 
absent in emphysema. 

2. When the pneumothorax is circumscribed the physical signs re- 
semble those of pulmonary cavity. But over a large cavity the chest 
is usually flattened ; cracked-pot sound and alteration in pitch upon 
opening and closing the mouth are more common in cavity than in 
jmeumothorax. Displacement of viscera does not necessarily occur 
in phthisical cavity, the coin-test is negative, succussion cannot be pro- 
duced. Fremitus is absent in pneumothorax and increased over a 
cavity. 

3. The hyper-resonance above a pleural effusion develops with a very 
different clinical history, is accompanied by increase of fremitus with 
bronchial or, at times, amphoric breathing, and changes when the 
patient's mouth is open or closed. The percussion-note usually lacks 
the metallic quality heard in pneumothorax, metallic tinkling is absent, 
the coin-test is negative. 

4. Pneumothorax must be distinguished from abscess below the dia- 
phragm containing air (pyo-pneumothorax subphrenicus). Often the 
distinction is difficult. The constitutional symptoms of supjDuration 
are present. Leyden points out the importance of remembering the 
sequence of events in the development of the disease. When the 
abscess is situated below the diaphragm, abdominal symptoms precede 
its development, and early in the course of the disease there is absence 
of respiratory symptoms. If the patient has had gastric ulcer, this 
would point to subphrenic abscess, as most of the cases of subphrenic 
abscess are secondary to gastric ulcer. Moreover, in subphrenic abscess 
the heart is not displaced nor the interspaces bulging. Indeed, the 
viscera below the diaphragm are more likely to be displaced than those 
above it. In pneumothorax, according to Leyden, the respiration is 



DISEASES OF THE LUNGS AND PLEURJE. 579 

normal under the clavicle, and the transitions from the normal to the 
metallic and amphoric sounds lower down are abrupt. In pyopneu- 
mothorax on the left side the semilunar space disappears. In sub- 
phrenic abscess the amphoric sounds laterally or posteriorly may be 
above and below the diaphragm, or they may be loudest at the epigas- 
trium. In addition, in pyo-pneumothorax subphrenicus, as Mason 
points out, adhesions of the lung to the diaphragm and parietes can be 
made out, particularly if the case has been under observation in its 
earlier stages and dry pleurisy has been discovered. Abscess in this 
location and slight fluctuation are likely to develop with associated 
effusion. The limited extent of the effusion is of diagnostic import in 
favor of sub-diaphragmatic inflammation. 



CHAPTER III. 

DISEASES OF THE HEABT, THE BLOODVESSELS, AND THE 
MEDIASTINUM. 

The symptoms of disease of the heart are due to the anatomical 
structure of the organ, to its physiological offices, and to the morbid 
process. The heart is a hollow muscular structure which hangs in a 
cavity and encloses cavities separated by valves. Both sets of cavities 
are lined by serous membrane. The serous membranes are subject to 
the same diseases, and present the same symptoms as diseased serous 
membranes elsewhere. In inflammation of the external membrane 
the surfaces rub together and create a sound of friction. The external 
serous cavity may also become filled with the products of exudation or 
transudation. Physical signs are produced. They are the physical 
signs of a localized increase of contents as determined by inspection, 
palpation, and percussion, and of physical interference with the heart's 
action. The heart-muscle is also subject to the same morbid processes 
as other muscular structures. They are hypertrophy and atrophy ; 
inflammation, acute and chronic, with overgrowth of connective tissue ; 
and degenerations. The symptoms are likewise the same. Increase 
or diminution in the power of the muscle is associated with correspond- 
ing change in size, which is determined by physical signs. Above 
all, however, such change modifies the heart's action so that strength 
or weakness of the muscle shows itself in excessive or deficient vascu- 
lar pressure. The latter is more particularly an object of observation 
because of the congestions, dropsies, and cyanosis that ensue. 

The heart is constantly subjected to internal pressure. Dilatation 
of the cavities or a portion of cavity (aneurism) follows previous dis- 
ease of the muscle or increase of internal pressure, and causes physical 
signs of enlargement. Degeneration of the heart-muscle, nearly always 
secondary to deficiency of vascular supply, is also attended by symp- 
toms of weakness and physical signs of enlargement (dilatation), or of 
diminution in size (atrophy). When dilatation occurs the orifices of 
the cavities enlarge, the valves cannot close them, and symptoms of 
incompetency and of blood-regurgitation result. 

The serous membrane that lines the cavities of the heart and, with 
the subserous tissues, makes up the structure of the valves, is subject 
to inflammations, the symptoms of which are common to all serous 
inflammations. The swellings and outgrowths that attend such in- 
flammation occlude the orifices and prevent closing of the valves. A 
physical interference with the heart's function is produced, recognized 
by physical signs. The successful effort of the heart-muscle to over- 
come such obstruction on the one hand (hypertrophy), or its failure on 
the other (dilatation), again leads to the production of symptoms and 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 581 

signs. The serous membranes, and hence the valves, are exposed to 
causes which excite inflammation. By virtue of the position of the 
heart at the centre of the circulation, the blood, infectious or irritative, 
as in rheumatism and Bright' s disease, constantly bathes the vulnerable 
structure. For the same anatomical reason positive symptoms arise, 
not common to serous membrane inflammation — that is, embolic phe- 
nomena. (See Symptoms of Morbid Processes.) Hence, the physical 
signs (objective symptoms) of cardiac disease may be due to primary 
and secondary morbid anatomical changes. They may be due (1) to 
valvulitis as indicated by signs of (a) obstruction or regurgitation at 
the valve-orifice, or (b) of embolic phenomena ; (2) to secondary changes 
in the heart-muscle as seen in (a) change in the size and strength of 
the organ (hypertrophy or dilatation), and (b) in consequence of the 
latter, signs of congestion, oedema, cyanosis, etc. 

It is the function of the heart to propel the blood. It has been 
shown how interference with the action of the muscle and with the 
consequent flow of blood through the cavities and orifices modifies the 
function. The functional power is increased or diminished by the 
physical changes. The evidence of increased power is increased force 
of the heart-beat, and increased pressure in the arteries (pulse). 

Diminished power shows itself in symptoms of diminished blood- 
supply to parts, and in stagnation of the blood that is sent to the 
periphery. The former is more pronounced in cerebral anaemia, and 
physiological weakness of organs or the organism as a whole ; the 
latter, in congestion and dropsies. 

The functional activity of the heart is controlled by a nervous mech- 
anism, any alteration of which alters cardiac action and consequently 
produces symptoms. Just as with the larynx, a break in the cardiac 
mechanism may be in the centres in the medulla, the centres in the 
muscle, or in the sympathetic nerves to and from the heart. The rich 
anastomosis of these nerves exposes the heart to disturbance by reflex 
influences. We should suppose such extensive innervation would in- 
vite frequent cardiac perturbation. In a measure it does, but, fortu- 
nately, so perfect is this mechanism that the inhibitory fibres control 
such perturbation to a large extent, and we do not see such pronounced 
symptoms as occur in the larynx. The symptoms which point to dis- 
turbance of the cardiac mechanism are alterations in the rhythm of the 
heart. Its action may on this account be increased or diminished in 
frequency, or it may be irregular or intermittent. Such alterations of 
rhythm may be due to organic disease of the centres, notably the pneu- 
mogastric from apoplexy, softening, or tumor in the medulla, or to 
stimulation or depression of the centres by toxic substances in the blood, 
as in uraemia, acetonemia, or autogenetic or other toxaemias, or by nico- 
tine or other extraneous material. The altered rhythm may be, and most 
frequently is, of reflex origin. It may be due to disease of the nerves, 
as the pneumogastric or sympathetic, from pressure upon the nerve-trunk 
by tumor or inflammatory growth. The most pronounced symptom of 
altered rhythm of which the patient is cognizant is palpitation. The 
exciting cause of this, as well as other rhythmical changes, must, in the 
great majority of cases, be sought for beyond the domain of the heart. 



582 SPECIAL DIAGNOSIS. 

AY bile the symptoms or signs of cardiac disease are often due to 
morbid processes in the organ or its membrane, it must be remembered 
that grave and persistent subjective and objective symptoms may be 
caused by, or at least associated with, disease of contiguous structures 
outside of the pericardium. The symptoms are not excited through 
the nervous system, but are produced by mechanical encroachment upon 
the organ, as in pleurisy with effusion, mediastinal disease and disease 
of subdiaphragmatic viscera. They will be referred to in the study of 
objective symptoms. Care must be taken never to overlook the possi- 
bility of their presence. 

In the study of the symptomatology of cardiac disease the student 
must bear in mind two things : first, that the cause of the morbid pro- 
cesses and of the symptoms (pain and palpitation) may be elsewhere 
than in the heart ; and, second, that the ultimate object of the exami- 
nation is to determine the muscular power of the heart. He will soon 
learn that with that power intact the functions can be performed, not- 
withstanding the presence of marked physical abnormalities. 

The recognition of disease of the heart is not usually attended by 
much difficulty, except in some special lesions. The non-recognition 
of cardiac disease is due to faults in the examination. The physician 
is too often satisfied with the recognition of the remote process, as a 
congestion or functional weakness in some organ. Safety lies, as has 
often been said, in the examination of all the organs of the body. 
Often, for instance, indigestion from gastric catarrh is not relieved, for 
the cause, mitral regurgitation, is not recognized. 

The Data Obtained by Inquiry. 

The Social History. The incidents in the social history to be 
considered in the determination of the presence of cardio-vascular dis- 
ease are those which notably influence by strain, excitement, or wear 
and tear, the cardio-vascular mechanism — those which alternately in- 
crease and diminish cardiac action, open and shut, dilate and contract 
peripheral vessels. Whether it be symptoms of functional disorder or 
of organic disease we wish to unravel, we must inquire as to the use 
of stimulants, of tea, coffee, tobacco, and other narcotics or poisons ; as 
to mental anxiety or physical strain ; as to excesses of various kinds. 
Excess in any form induces vascular Avear and tear. Tersely put by 
one of our most distinguished clinicians, the devotee at the shrine of 
Venus, Bacchus or Mars, is too frequently the victim of vascular dis- 
ease. Occupations which invoke such vascular excitations are sugges- 
tive diagnostic factors. 

The age in which we are wont to find cardio-vascular affections 
varies with the character of the lesion. Apart from congenital cardiac 
affections, acute inflammations are more common at the age when infec- 
tious are more operative, as in the early decades. On the other hand, 
and it goes without saying, degenerative lesions are found in later life. 
But as man is no older than his arteries, and as these degenerative 
Lesions may occur in comparatively early life, from a cardio-vascular 
stand-point, a man may be senile at thirty-five or even earlier. Sex 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 583 

influences diagnosis in so much as the one sex is more exposed to the 
causal influences of cardiac lesions. Females are more prone to acute 
infectious processes and to the neuroses from immobile nervous systems. 
Males to degenerative lesions and the intoxication neuroses. 

Family History. Inquiry in this direction yields information of 
great diagnostic value. The gouty and rheumatic diatheses, with 
their long train of associated disorders, which predisposes to cardio- 
vascular affections, are notably inherited. Moreover, the tendency to 
atheroma of vessels is itself pronouncedly hereditary. 

The History of Previous Disease. The occurrence of any one 
of the numerous infections may have been the initial step in the pro- 
duction of the affections we are considering. The determination of 
the nature of a cardiac lesion may hinge upon the correct decision of 
this question. The infection of acute rheumatism is of course to be 
eagerly sought for. A history of chorea, of various skin affections 
related to gout and rheumatism, of eye affections, of tonsillitis, of other 
affections related to the so-called uric-acid diathesis, must be sought 
for. If found, such history is more than suggestive. 

The Subjective Symptoms. A. Symptoms Referred to the 
Heart. Pain. 1. In Disease Outside of the Heart. Although pain 
in the region of the heart may be a symptom of disease of that organ 
or of the pericardium, in the large majority of instances it is due to 
other causes. The physician is frequently consulted by the anxious 
patient on account of pain, other than heart-pain, but referred to this 
region, or more precisely to the fifth or sixth interspace on the left 
side. The causes of such pain are various : (1) Neuralgia ; (2) pleu- 
rodynia ; (3) myalgia ; (4) local pleurisy ; (5) periostitis. The neu- 
ralgias may be associated with points of tenderness, Avhich are usually 
the seat of the greatest intensity of the pain. These points of tender- 
ness correspond with the positions at which the nerves have their 
exit through the fascia to the surface, and are found along the 
sternum, in the course of the mid-axilla, and along the vertebra?. The 
pain is paroxysmal, occurs at variable periods of the day, and in 
anaemic subjects or in the course of neurasthenia. It may precede the 
development of herpes zoster. In these cases the exact nature of the 
pain is not known until the eruption appears. In gout or diabetes we 
may have local neuritis, which causes neuralgic pain in this situation. 

Pleurodynia, which is thought to be an affection of the pleural 
nerves, is more general. The pain is increased by pressure of the 
finger-tips, although it is not localized. It is relieved by pressure of 
the whole hand. In myalgia, which is seen so frequently in phthisis, 
on account of severe coughing, in rheumatism and in debilitated subjects 
generally, the pain is more or less diffuse, interferes more or less with 
movements of the chest, is relieved by uniform general pressure, and 
is usually associated with myalgia in other organs. The pain of pleu- 
risy is recognized by the fact that it usually inhibits the act of breath- 
ing, and is associated with cough, and because friction-sounds may be 
detected. Periostitis. In disease of the ribs of the prsecordia the pain 
is associated with tenderness and swelling. One or more of the costo- 
sternal articulations may be extremely tender. The pain and tender- 



584 SPECIAL DIAGNOSIS. 

ness are due to the periostitis of syphilis or to that which follows 
typhoid fever. In one of my cases the rib had to be resected. It 
may be due to the internal pressure and erosion of ribs in aneurism. 
The same affection may cause neuralgic pains in the nerves. Abscess. 
Pain in this region may, in rare instances, be due to localized tuber- 
culous abscess between the pericardium and the walls of the thorax. 
One such case was under my care. The abscess developed secondarily 
to empyema and occupied the precordial region, causing bulging. 
The pain was intense, and was only relieved after the caseating pus 
was removed by incision. 

Pain in the epigastrium is often held to be due to cardiac disease. 
It is usually due to gastralgia, or, as it is sometimes termed, cardial- 
gia. It is recognized by the location of the pain and its association 
with gastric symptoms, as flatulency, weight, fulness, and acidity. In 
gastric ulcer the epigastric pain is localized, accompanied by tender- 
ness on pressure, and is increased by food. However, acute, severe, 
and excruciating pain in the epigastrium may be due to rupture of the 
heart and also to pericarditis. 

2. In Disease of the Pericardium. Pain in the region of the heart 
is sometimes due to affections of the pericardium. Pericarditis is the 
most common. While centralized in the heart-region, it may radiate 
to the left shoulder and extend down the arm. It is paroxysmal and 
may have some of the characteristics of angina. It is increased by 
movement, by pressure, and by the action of the diaphragm. The 
patient is often obliged to sit up in bed and suffers from orthopnoea. 
It may be referred to the epigastrium. A pericardial friction-sound is 
usually detected. Pain due to disease of the aorta. Acute inflammation 
of the aorta is also the cause of cardiac pain. The pain extends along the 
course of the aorta, may be referred to the sternum, and extends along 
the spine. The pain is severe, causing an anxious countenance and 
an expression of extreme suffering. In gouty subjects with atheroma 
pain may occur in this situation in paroxysms. There is usually val- 
vular disease at the aortic orifice. Similar pain occurs in syphilis and 
in alcoholic subjects, and may be due to malaria. It is a visceral 
neurosis, or a form of neuralgia. 

Pain in the region of the heart is frequently due to aneurism. The 
pain is usually due to pressure of the aneurism upon adjacent struc- 
tures. If it presses on the bone and causes erosion, the pain is of a 
boring character, localized at one point. It has been previously re- 
ferred to. In aneurism alone, without pressure, the pain is of a dull 
aching character, increased by movement, relieved by rest, or by 
change of position. When nerves are pressed upon, pain may be acute 
and of a neuralgic nature. It may follow the course of the nerves and 
be associated with numbness or sensations of tingling. The long dura- 
tion of the pain, its localization, and its aching character are sufficient 
to exclude angina pectoris. When the pain is unilateral it may be 
due to pressure of an aneurism upon the nerves at their exit from the 
canal ; the pain extends along the course of the intercostal nerves. It 
i- severe and burning, but there are no localized points of greater in- 
tensity. The pain may extend down the arms, and, when the abdomi- 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 585 

nal aorta is affected, it may extend down the legs. If rupture of the 
aneurism takes place, the pain is sudden and sharp. Death, however, 
ensues quickly, so that the pain will rarely be complained of. 

3. In Disease of the Heart. Three forms are seen : (1) Pain due to 
disturbances of the rhythm ; (2) pain due to valvular disease ; (3) pain 
due to angina pectoris. 

Disturbance of the Rhythm. Palpitation, intermission, and irregu- 
larity of the heart occur in the large majority of cases without pain. 
Paroxysms of palpitation are sometimes attended with severe precor- 
dial pain and distress. This occurs in the reflex palpitation, which, 
as will be seen, is due to disease in other situations ; in the palpitation 
of Graves' disease and of anaemia. The palpitation of organic disease 
is induced by exertion. The rapid action of the heart is painful and 
the throbbing is complained of as causing distress. 

While intermission and irregularity may continue without pain at 
times, the patient is conscious of this disturbance of the rhythm, and 
complains of the stoppage, which then is attended by distress, some- 
times amounting to severe pain. This is particularly the case when 
the heart-action is tumultuous, as the disturbance of rhythm seen in 
pericarditis and in valvular disease. 

Pain due to Valvular Disease. In disease of the aortic valves pain 
is of more frequent occurrence than in other valvular lesions. It is 
usually complained of in the region of the aorta at the base of the 
heart, and is aggravated by exertion. (See Atheroma.) 

Pain due to Angina Pectoris. Heberden was the first to describe the 
attacks of angina pectoris, which, in its typical form and in association 
with disease of the heart, is not of common occurrence. The pain of 
angina is severe and is associated with the most intense anguish. It 
comes on suddenly, and may occur in paroxysms. The patient real- 
izes that the pain is in the heart, and complains of feeling as if the 
organ were held in a vise. From the heart it radiates to the neck 
and down the arms. It extends particularly to the left arm, and may 
be severe in the wrist or in the ends of the fingers. With the pain 
there is a sense of impending death with sinking and depression. The 
pain lasts but a few seconds or minutes, and during that time the face 
of the patient becomes pale or of an ashy hue, perspiration breaks out 
on the forehead, the extremities become cold, the breathing is short. 
Prostration usually follows the attack, but the precordial distress dis- 
appears entirely. The attack may occur in patients who are entirely 
free from organic disease of the heart. It is most commonly, however, 
associated with some lesion. The lesions frequently found are disease 
of the coronary arteries, atheroma of the aorta, aortic valvular disease, 
and myocarditis with fatty degeneration. It occurs after middle life, 
and is more frequent in males. It may occur without exciting cause, 
or follow undue exertion, exposure to cold, mental excitement, or pro- 
found emotion. 

The points upon which the diagnosis is based are : 1. The seat of 
the pain. This is usually behind the middle or the lower part of the 
sternum, and more to the left than to the right. Thence it extends to 
the posterior portion of the axilla or it may radiate up to the neck. 



586 SPECIAL DIAGNOSIS. 

In some instances it extends to the occiput. Frequently the pain ex- 
tends to the left arm as far as the elbow or even the fingers. It may 
extend to the abdomen or to the right arm. I have seen it affect both 
arms. It is not influenced by external pressure. 2. The sense of 
constriction with the indescribable torture are most characteristic. 3. 
The respirations are shallow, or may even cease, but there is no dysp- 
noea. 4. The patient is terrified and restless. 5. The pale face, ex- 
tremely anxious countenance, the cold sweat on the forehead, make a 
striking picture, which when once seen can never be forgotten. 6. 
Such extreme depression and sensation of impending death occur in no 
other affection. Particularly characteristic is the immediate relief, 
without hysterical manifestations or dyspeptic symptoms of any kind, 
which follows an attack. 7. During the attack the frequency of the 
pulse is not much influenced, and the action of the heart may be uni- 
form and regular. Rarely its frequency may be lessened. The tension 
of the pulse is increased during the attack. 

Some authors speak of various grades of angina, and call all forms of 
precordial pain and oppression, with radiation of the pains to the arms 
and neck, mild forms of angina. Such attacks have often obvious 
causes in disturbance of digestion and in emotional excitement. When 
associated with increased arterial tension and signs of arterio-sclerosis, 
they may be of an anginoid nature. The greatest difficulty exists in 
distinguishing them from true angina. Hysterical or pseudo-angina 
can be distinguished only with extreme difficulty. It occurs much 
more frequently than true angina. One attack seems to predispose to 
others. It occurs in females who present other symptoms of hysteria. 
It occurs usually before forty years of age. The attacks most fre- 
quently come on at night, and may be periodical. They are particu- 
larly associated with menstrual disorders. The pain is less severe and 
the oppression is not so marked in pseudo-angina ; coldness of the 
hands and feet, with the occurrence of syncope, or a general feeling of 
sinking, are 'common symptoms. The pain is of long duration and is 
associated with great agitation. It is preceded by neuralgia, and 
neuralgic pains persist after the attack. Low tension, feeble second 
sound, and soft arteries may be present, although the opposite is also 
seen. The disease is never fatal. In one of my patients attacks of 
hysterical haemoptysis alternated with the anginal attacks. 

Palpitation. In palpitation the patient is conscious of the action 
of the heart. Although it may occur in organic disease, it is more 
frequently due to disease outside of the heart. 

Symptoms. The symptoms vary in degree. En mild forms the 
patients may complain of a fluttering or a sensation of sinking in the 
precordial region. In the more severe forms the heart beats violently 
against the chest. The arteries throb, the action of the heart is in- 
creased, and the area of impulse against the chest-wall is enlarged and 
visible. The patient complains of distress in the precordial region. 
The pulse may be increased to 150. In nervous palpitation the face 
becomes flushed, and after the attacks large quantities of urine are 
passed. Sometimes, in this form of palpitation, exertion relieves the 
attack. On examination, the sounds are found to be normal, but they 



DISEASES OF HEART, BLOODVESSELS AND- MEDIASTINUM. 587 

are clear and metallic in character. The diastolic sounds are greatly 
accentuated. If anaemia is present, murmurs due to that condition 
are increased in intensity. The attack may last but a few minutes or 
continue for hours. 

(a) It is most common in cases in which the nervous system gener- 
ally is in a state of increased excitability. Attacks occur at puberty 
and at the menopause. It is very common in hysteria and neuras- 
theniac It follows emotional disturbance. It is more frequent in women. 

(6) It is due to the action of the toxic substances, as tobacco, tea and 
coffee, and alcohol. 

(c) From strain and over-exertion, particularly if associated with ex- 
citement, palpitation may occur and continue for a long period. This 
is the form of irritable heart described by Da Costa, common in young 
soldiers during the war. 

(d) In valvular disease of the heart when compensation fails, and 
in myocarditis, attacks of palpitation occur, distinctly from exertion. 

Intermission and Irregularity. When the patient feels the alter- 
ation in rhythm, it is usually due to nervous disturbance. In organic 
disease it is not, as a rule, appreciated by the patient. Although not 
a subjective symptom alone, it may be well to speak of irregularity in 
this connection. 

Arrhythmia is the general term applied to irregularity of the action 
of the heart. When the heart intermits — that is, when one or two 
beats are dropped at intervals of half a minute, a minute, or longer ; 
when the beats are unequal in volume and force, or occur at unequal 
distances in time, the heart's action is irregular. The causes of dis- 
turbance of the rhythm have been classified by Baumgarten 1 as follows : 

1. Central causes in the medulla either from organic disease, as 
hemorrhage or concussion, or from physical influences. 2. Reflex 
influences, as in dyspepsia and diseases of the liver, lungs, and kid- 
neys. 3. Toxic influences — tobacco, coffee, and tea are common causes ; 
various drugs, such as digitalis, belladonna, 'and aconite. 4. Changes 
in the heart itself. Mural changes, as in dilatation, fatty degeneration, 
and myocarditis ; changes in the cardiac ganglia ; sclerosis of the cor- 
onary arteries. 

It must not be forgotten that both irregularity and intermittency 
may occur in persons otherwise in good health, and continue for a long 
period of time without any evidence of arterial or cardiac disease. 
(For the varieties of arrhythmia, see The Pulse.) 

B. Symptoms Referred to the Circulation. 1. Pulsation of 
the Arteries. Pulsation of the arteries, especially the carotids, the 
abdominal aorta, and the brachial arteries, occurs in anaemia, and is 
common in emotional disturbances. Such pulsation, as of the abdomi- 
nal aorta, may be reflex from organic disease in the vicinity. Similar 
localized pulsation in the innominate arteries may be mistaken for 
aneurism. The pulsation that attends organic heart disease may be 
due to hypertrophy of the heart, but is particularly characteristic of 
aortic regurgitation. 

1 See Transactions of the Association of American Physicians, vol. iii. 



588 SPECIAL DIAGNOSIS. 

2. Hemorrhages. In the description of valvular lesions it will 
be seen that hemorrhages from the lungs occur quite frequently in 
disease of the mitral valve. The hemorrhage may be due to conges- 
tion, to actual rupture of the vessels, or to hemorrhagic infarct. (See 
Pulmonary Hemorrhage.) It may simulate hemorrhage due to tuber- 
culosis. 

3. Cyanosis. Cyanosis is a symptom of common occurrence in the 
course of organic heart disease. 

4. Dropsy. The dropsy of heart disease occurs after failure in 
compensation in the course of valvular disease, and in dilatation of 
the heart. It may disappear entirely, if the conditions are improved, 
or become permanent and progressive. In general, it may be said to 
be distinctly a phenomenon of mitral regurgitation and secondary 
tricuspid regurgitation. It occurs in a lesser degree in mitral obstruc- 
tion, and still less in disease at the aortic orifice. 

C. Symptoms Referred to the Lungs. The chief subjective 
symptom is dyspnoea. Dyspnoea, due to disease of the heart, is clini- 
cally divided into (1) dyspnoea caused or increased by exertion ; (2) 
paroxysmal dyspnoea ; (3) orthopnoea ; (4) rhythmical dyspnoea, or 
Cheyne-Stokes respiration. The dyspnoea of effort comes on after 
the slightest exertion. In paroxysmal dyspnoea the attack comes on 
without apparent cause. It must be distinguished from the paroxys- 
mal dyspnoea of uraemia, asthma, or emphysema. The physical signs of 
lung disease usually point to the latter. The paroxysmal dyspnoea of 
heart disease is attended by more violent efforts in breathing than the 
physical state of the lungs admits, and the difficulty attends both in- 
spiration and expiration. Wheezing is not so marked as in forms of 
asthma. There is some obstruction to the outgoing of air ; but, on 
account of air-hunger, all the efforts of the patient are exerted to fill 
the chest. In paroxysmal dyspnoea the breathing usually becomes 
quiet if the patient is placed in a comfortable position, provided there 
is no lung or pleural complication. The position does not modify the 
severe dyspnoea of asthma or emphysema. Orthopnoea has been 
described previously. 

Cough. Cough is of frequent occurrence in heart disease. The 
causes are various. It may be due to pressure upon the bronchus or 
the pneumogastric nerves, as in pericardial effusion. It may be due 
to the passive congestion of the lungs which occurs in failing compen- 
sation. If hemorrhagic infarcts take place, cough may be present. It 
attends the bronchopneumonia that follows. In cough from pressure 
of an aneurism a metallic brassy sound is created. (See The Larynx.) 
It occurs in paroxysms, and may be associated with alterations in the 
voice. It may result in the expectoration of blood-tinged sputum, 
which may be due to the gradual rupture of the aneurism. 

D. Symptoms Referred to the Nervous System. The symptoms 
are usually due to disturbance of the cerebral circulation, because either 
an insufficient quantity of blood ,or improperly oxygenated blood is 
supplied to the brain. Vertigo, faintness, and languor are complained 
of in the first instance. Dulness, stupor, and moderate delirium (car- 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 589 

bon-dioxide poisoning) may occur in the later stages in the second 
instance. In the course of organic heart disease epilepsy or epileptiform 
convulsions may arise, on account of embolism or thrombosis. Chorea 
is of common occurrence, and apparently of the same cause as the 
heart disease. China may be due to hemorrhage into the brain, to 
embolism, or to thrombosis. Hemorrhage occurs in patients in whom 
there are usually found hypertrophy of the left ventricle, atheroma of 
the arteries, and renal disease. Embolism occurs in valvular disease, 
particularly in aortic regurgitation and mitral obstruction. We may 
have the occurrence of paralysis for the same reason, with or without 
coma. The Stokes- Adams syndrome of vertigo, syncope, loss of con- 
sciousness, and slow pulse — pseudo-apoplexy — is seen in myocarditis 
and endarteritis. 

Thrombosis in the course of heart disease is usually due to disease 
of the bloodvessels rather than to disease of the heart itself, although a 
weakening of the heart, as in dilatation, is a factor predisposing to the 
development of thrombosis. 

E. Symptoms Referred to the Alimentary Canal. In the 
course of organic heart disease dyspepsia and forms of catarrhal gastritis 
and enteritis are of common occurrence. Patients complain of various 
forms of indigestion, or of nausea and vomiting. While water-brash and 
flatulence are caused primarily by the condition of the heart, they may 
in their turn cause symptoms of palpitation and cardiac distress. These 
gastric difficulties are more particularly seen in diseases of the auriculo- 
ventricular valves, and are associated with congestion and secondary 
cirrhosis of the abdominal viscera. 

F. Symptoms Referred to the Throat. The patient may com- 
plain of pain in the throat. This may be paroxysmal, and is some- 
times said to be due to angina pectoris. Hoarseness or modifications 
of the voice are occasional symptoms of pericarditis. They are of fre- 
quent occurrence in the course of aneurism due to pressure upon the 
recurrent laryngeal nerves. 

G. Symptoms Referred to the Kidneys. The kidneys are inti- 
mately related with the heart at a distant point in the circulation, and 
are frequently the seat of changes due primarily to disease of the central 
organ of circulation. The changes in the urine will be referred to 
again ; suffice it to say, that in the course of mitral and tricuspid 
disease and dilatation, scanty urine, of high color, loaded with urates, 
containing a small amount of albumin, is quite common and indicative 
of passive congestion of the kidney. It may result in cyanotic indura- 
tion or interstitial nephritis. On the other hand, the urine may be of 
low specific gravity and pale in color. There may or ma3 r not be 
traces of albumin. The change is due to a granular, contracted kidney , 
which is associated with hypertrophy of the left ventricle and arterial 
sclerosis. Bloody urine is usually due to renal embolism when it occurs 
suddenly in the course of organic heart disease. It may be due to 
the emboli that are found in septic endocarditis. Renal disease in all 
forms may complicate disease of the heart. (See Kidney Disease.) 

The Subjective Symptoms of Arterial Disease. The patient 
may have symptoms of congestion or of anaemia of the brain. Headache, 



590 SPECIAL DIAGNOSIS. 

vertigo, photophobia, tinnitus, and paresthesia, due to either cause, may 
prevail. (See also Cerebral Thrombosis.) The diseased vessels prevent 
the blood from reaching the extremities, hence they are cold. Pain is 
common only when atheroma or aneurism is present (q. v.). Throbbing 
or pulsation is complained of. It may be a striking feature of hysteria 
and neurasthenia. The abdominal aorta is frequently thus affected. 
The pulsation may be constant or intermittent. There may be dys- 
peptic symptoms. The pulsation of the carotids may cause disagree- 
able sensations in the head, and the beating transmitted to the ear be a 
source of extreme annovance. 



The Data Obtained by Observation. 

Before describing the methods of observation it is well to review 
some of the facts of anatomy and physiology essential to the accuracy 
of any observations. 

Topographical Anatomy. (Plate XIII.) Outline of Heart 
on Chest-wall. 1 

To have a general idea of the form and position of the heart, map 
its outline on the wall of the chest as follows : 

(«) To define the base — i. e., the part to which its great vessels are 
attached — draw a transverse line across the sternum, corresponding 
with the upper borders of the third costal cartilages ; continue the line 
half an inch to the right of the sternum and one inch to the left. 

(b) To find the apex, mark a point about two inches below the left 
nipple, and one inch to its sternal side. This point will be between 
the fifth and sixth ribs. 

(c) To find the lower border (which lies on the central tendon of the 
diaphragm), draw a line, slightly curved downward, from the apex 
across the bottom of the sternum (not the ensiform cartilage) as far 
as its right edge. 

(d) To define the right border (formed by the right auricle), continue 
the last line upward with an outward carve, so as to join the right 
end of the base. 

(e) To define the left border (formed by the left ventricle), draw a 
line curving to the left, bat not including the nipple, from the left 
end of the base to the apex. 

Such an outline shows that the apex of the heart points downward 
and toward the left, the base a little upward and toward the right ; 
that the greater part of it lies in the left half of the chest, and that 
the only part which lies to the right of the sternum is the right auricle. 
A needle introduced in the third, fourth, or fifth right intercostal 
space close to the sternum would penetrate the lung and the right 
auricle. 

A needle passed through the first intercostal space close to the right 
side of the sternum would pass through the lung and enter the supe- 
rior vena cava above the pericardium. 

1 From Hoi don : Landmarks, Medical and Surgical. 



DFSEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 591 

The best definition of that part of the precordial region which is 
less resonant on percussion was given by Dr. Latham years ago in his 
" Clinical Lectures." " Make a circle of two inches in diameter round 
a point midway between the nipple and the end of the sternum. This 
circle will define sufficiently, or for all practical purposes, that part 
of the heart which lies immediately behind the wall of the chest and 
is not covered by lung or pleura." 

Valves of the Heart. The aortic valve lies behind the third 
intercostal space, close to the left side of the sternum. 

The pulmonary valve lies in front of the aortic behind the junction 
of the third costal cartilage with the sternum, on the left side. 

The tricuspid valve lies behind the middle of the sternum, about 
the level of the fourth costal cartilage. 

The mitral valve (the deepest of all) lies behind the third intercostal 
space, about one inch to the left of the sternum. 

Thus these valves are so situated that the mouth of an ordinary- 
sized stethoscope will cover a portion of them all, if placed over the 
sternal end of the third intercostal space, on the left side. All are 
covered by a thin layer of lung ; therefore we hear their action better 
when the breathing is for a moment suspended. 

Physiology. Action of the Heart The heart beats — that is, alter- 
nately contracts and dilates or relaxes — 65 to 85 times per minute in 
an adult. In females, the frequency varies from 75 to 85 ; in males 
from 65 to 75. With each beat, blood is propelled throughout the 
vascular channels of the body, and drawn from them to the heart- 
chamber. The first effect is produced by the contraction of the heart, 
or the systole ; the second by the relaxation, or diastole. Other events, 
as the act of respiration, contribute to the completion of the outflow 
and inflow of blood, particularly to the latter. 

The completion of the act of contraction and the act of dilatation 
make up one revolution of cardiac action, or, as it is termed, a cycle- 
Events of the Cardiac Cycle. The following events make up the 
cardiac cycle. The act of contraction is the systolic period of the 
cycle ; that of relaxation is the diastolic period. During the systole 
(1) the ventricles contract ; (2) the auriculo-ventricular valves close ; 
(3) the blood is propelled from the ventricles into the vessels, the 
columns of blood in the aorta and pulmonary artery receive a shock 
from the impact of the new volume of blood, and their bulk increases. 
The movement of the blood-wave from this cause and from the con- 
traction of the large vascular trunks produces pulsation of the periph- 
eral vessels, which is known as the pulse. The contraction is imme- 
diately followed by relaxation — the diastole. (1) The blood-columns 
in the aorta and in the pulmonary artery fall back upon the valves 
guarding their outlets, the aortic and pulmonary valves. At the same 
time (2) the auricles are filled by the blood pouring in from the veins. 
(3) The auricular muscles contract upon the blood in the chamber, 
driving it into the ventricles. 

The systolic and the diastolic periods of a cardiac cycle are nearly 
equal in the length of time occupied in their occurrence. The systolic 
period occurs at the same time, or is synchronous with the apex-beat 



592 SPECIAL DIAGNOSIS. 

and carotid pulse, and precedes by a fraction of a second the radial 
pulse. It is immediately followed by the diastolic period, which, 
therefore, follows the carotid and radial pulse. 

Inspection. The Heart. The Method of Examination. The 
patient should be stripped, and a good light should fall directly, as well as 
obliquely, on the surface. The patient can be examined in any position, 
and indeed for accuracy should be examined both in the upright and 
recumbent postures. This is particularly true when the pulse-rate is 
taken and when auscultation is practised. The sounds vary frequently 
in different positions. Some diagnostic significance is attached to 
Ihese variations. It is necessary sometimes to have the patient lean 
forward, to bring the heart into more immediate contact with the 
chest- wall. 

The examination should not be confined to the heart and vessels. 
The reader will remember that in the account of the exterior and 
of local areas it was pointed out that various abnormal conditions 
may be due to disease of the heart. In the examination, therefore, 
of a case of suspected heart disease, observation is made of the gen- 
eral and of the local color, as of the lips, the fingers, and the con- 
junctivse, to determine the presence of cyanosis, pallor, or jaundice ; 
of the feet, to discover dropsy ; the face, to note the appearance of 
the countenance ; the neck, to note the state of the vessels ; the eyes, 
to note their prominence ; the thorax, to ascertain the presence of 
dyspnoea. 

The Pr^ecordia. The prsecordia is the region of the chest which 
overlies the heart. In the study of the appearance of the prsecordia 
we observe : 1. The degree of prominence or swelling. 2. The impulse 
and other pulsations. 3. The interspaces. 4. The hue of the surface. 

The Prominence. The prsecordia may be unduly prominent in 
children who have had rickets and possibly some cardiac hypertrophy 
in childhood. It persists in later life. The ribs as well as the soft 
tissues are prominent. The lower end of the sternum may project. 
Swelling also occurs in hypertrophy or dilated hypertrophy of the 
heart, in pericardial effusions, localized pleural effusions and pointing 
empyema, and in aneurisms in the region of the heart. In pericardial 
effusion ribs and interspaces project. The latter are full or even with 
the surface. The prominence of cardiac disease is observed between 
the third and seventh ribs on the left side, and extends from the left 
nipple to the sternum, and even as far as the right nipple. The dis- 
tance from the middle of the sternum to the mid-axilla is greater on 
the left than on the right side. Local bulging may be seen at the 
apex in cases of aneurism of the heart. 

The prsecordia may be sunken. Old pericarditis, but more fre- 
quently old empyema, causes sinking in of the region. It may be a 
result of rickets or of spinal curvature. 

The Impulsp:. The normal impulse is that portion of the heart 
which strikes the chest-wall, and is improperly known as the apex-beat. 
It is evident in health in the fifth interspace just inside of the mid- 
clavicular line. It can readily be detected by inspection with a good 
light, in patients with moderately thick chest-walls. It is due to the 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 593 

impulse of the right ventricle, three-fourths of an inch above the apex, 
against the chest-wall when the heart contracts, and hence it is systolic 
in time. 

Changes of Position in Health. It is not a fixed point in 
health. It moves with the movements of the body, and hence, when 
the trunk is inclined to the left, the impulse falls toward the left 
axilla as far outward as the mid-clavicular line or even beyond that 
point. It moves toward the right and downward in full inspiration, 
or may disappear entirely toward the completion of that act. It may 
not be observed if there is a large amount of subcutaneous fat, or if 
the mammary gland intervenes. It becomes more conspicuous at the 
end of expiration or when the body is inclined forward. In children 
it is higher (fourth interspace) and more to the left. It is depressed 
in old people. It must be remembered that in transposition of the 
viscera the position of the impulse is changed. 

Change of Position in Disease. The apex-beat, or the lowest 
point of impulse, may be displaced or may be absent entirely. These 
changes are due either to (a) disease outside of the pericardium, to (6) 
disease within the pericardium, or to (c) disease of the heart itself. 

I. Displaced to the Left. This occurs from (a) Alterations 
outside of the Pericardium. When the right lung is the seat of exten- 
sive compensatory emphysema, or the right pleura is filled by a large 
effusion, the impulse is displaced to the left. On the other hand, 
fibroid phthisis of the apex of the left lung, or pleural adhesions which 
have become attached to the pericardial sac, with, probably, coincident 
pericarditis, pull the heart to the left, thereby changing the position of 
the impulse. In disease of the mediastinum the heart is pushed down- 
ward and toward the left. An aneurism, an abscess, or enlarged glands 
in this situation may invade the normal cardiac territory and cause 
dislocation of the heart. 

In disease of the abdomen the impulse is displaced. If the liver 
and spleen are enlarged, or the abdomen distended by ascites, the 
diaphragm is raised, and, therefore, also the heart. The impulse is 
then seen to the left of the normal position, and may be one or two 
interspaces higher than normal. A common physical change in the 
stomach — dilatation — is a frequent source of displacement of the im- 
jmlse. The dilatation may be temporary from flatulency or may be 
due to organic disease. 

(6) Alterations within the Pericardium. In cases of pericardial 
effusion the impulse is shifted to the left and upward. It is seen in 
the fourth and even as high as the third interspace, and sometimes 
only an impulse is noted in the second interspace. This, however, is 
not the true apex. Instead, we undoubtedly see in pericardial effu- 
sions the impulse of the right auricle and the conus arteriosus against 
the chest-wall. 

(c) Diseases of the Heart. The impulse is diplaced to the left in 
dilatation and hypertrophy of the heart. In the latter it is also dis- 
placed downward. It may be as low as the sixth or seventh interspace 
and extend as far to the left as the anterior axillary or the mid-axil- 
lary line. 

38 



594 



SPECIAL DIAGNOSIS. 



II. Displaced to the Right, (a) Alterations outside of the Peri- 
cardium. The heart is dislocated to the right in left pleural effu- 
sion, and in emphysema of the left lung. We find, moreover, in 
pleural contractions and fibroid phthisis of the right lung the heart 
drawn to that side. Under these circumstances the impulse is noted 
either in the epigastric region, along the margin of the ribs, or even 

Fig. 152. 




Normal and abnormal impulses. 
1. Normal position of impulse. 2. Displacement to left and downward. 3. Displacement to left 
and upward. 4. Impulse from enlarged right ventricle. 5. Displacement to right. 6. Dilated 
right auricle. 7. Displacement in fibroid phthisis. 8. Impulse of conus arteriosus. (Errata : 
"8" should be in 2d interspace parasternal line.) 9. Fibroid phthisis, right lung. 

to the right nipple-line, in any interspace from the third to the sixth, 
along the right edge of the sternum. The impulse in the epigastric 
region usually represents the hypertrophied right ventricle, which 
usually attends the lung-changes that cause displacement of the apex- 
beat. The impulse along the right edge of the sternum may be the 
apex-beat, or the right auricle and the right ventricle brought in appo- 
sition to the chest- wall by the cardiac dislocation. The apex or the tip 
of the heart is, in all probability, displaced but little beyond the mid- 
sternal line. (6) The impulse is not displaced to the right in alter- 
ations within the pericardium, or (c) in disease of the heart. 

III. Absent. Following the same order, we find that the impulse 
may be absent entirely in (a) disease outside the pericardium, on account 
of which something intervenes between the heart and the chest-wall. 
Hence, in emphysema of the lungs and in compensatory emphysema 
of the left lung the impulse is entirely effaced ; in (b) disease of the 
pericardium the impulse is absent when there is large effusion. The 
absence here succeeds the dislocation to the left, and with its efface- 
ment the impulse in the second and third interspaces disappears. In 
{<•) disease of the heart the impulse is absent when the heart is dimin- 
ished in size, as in atrophy, or in myocarditis, or when weakened by 
fatty degeneration or dilatation 

The Extent of the Impulse. In health the impulse is limited 
in extent to about one square inch. The area of impulse may be in- 






DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 595 

creased when the individual leans forward, and at the end of expira- 
tion. It is more evident when the chest-walls are thin, and less when 
they are thick. 

Extent in Disease. The area of impulse may be increased. The 
causes are : (a) Diseases outside of the pericardium. The area is in- 
creased in chronic phthisis with fibrous adhesions, and in pleural adhe- 
sions when the lung is drawn away from the surface of the heart. It 
is increased when the heart is pushed against the chest- wall, as in 
aneurism or in diseases of the mediastinum, from inflammation or 
cancer, or other mediastinal growth. The impulse is seen not only in 
the third and fourth interspaces, but also as high as the second, and is 
not limited to the spaces between the sternum and parasternal lines, 
but may extend beyond the mid-clavicular line. It may not be systolic in 
time only, but diastolic, presystolic, and systolic, and have the appearance 
of a peristaltic wave from base to apex. The time coincides not only 
with contraction of the ventricles, but also of the auricles, and of the 
closure of the semilunar valves. (b) Disease of the pericardium tends 
to increase the area of impulse if moderate effusion is present. It will 
be seen as a diffuse wave occupying the second, third, and fourth in- 
terspaces. It is also increased in pericardial adhesions, without increase 
in strength, (c) Disease of the heart. The heart must be enlarged, 
and hence must either be hypertrophied or dilated. The extent of 
impulse varies. In hypertrophy the impulse may be communicated 
to the sternum, so that the lower part heaves with each contraction. 
It falls below the fifth interspace and toward the left, particularly if 
the left ventricle is the seat of the enlargement. If the right ventricle 
is hypertrophied, the impulse is very marked in the third, fourth, fifth, 
sixth, and even the seventh interspaces near the termination of the 
cartilages, or in the epigastrium along the border of the ribs of the 
left side. It may be seen in anaemia in this situation, particularly in 
persons whose respirations are habitually shallow. Sometimes, when 
associated with and displaced by lung disease, it is seen to the right 
of the xiphoid cartilage. 

New Impulse. New areas of impulse, the heart not dislocated, 
arise from enlargement of one of the cardiac chambers or from disease 
of the bloodvessels. A new area of impulse in the second or third 
interspace on the left is from the conus arteriosus, or is due to hyper- 
trophy and dilatation of the right ventricle ; or it may be due to 
retraction of the lung in that region. It may be due to a dilated right 
auricle, and is then seen in the fifth right interspace along the sternum. 
If the impulse is noted in the course of or adjacent to the aorta, it is 
indicative of aneurism. 

The Interspaces. They are retracted possibly from pericardial 
adhesions ; they are full or bulging in effusion. This retraction may be 
limited to the apex or may occur in each interspace over the precordial 
region. It may occur with the systole or with the diastole. It may 
occur in hypertrophy of the heart, and is then systolic in time. It is 
of some, although doubtful, diagnostic significance when it is systolic 
in time, as it is said to indicate adhesions of the pericardium. The 
traction at the systole of the heart causes the interspaces to be drawn in. 



596 SPECIAL DIAGNOSIS. 

On inspection behind, a systolic retraction of the interspaces is seen 
in adherent pericardium, known as Broadbentfs sign. 

Color of Surface. Only when purulent pericardial effusion is 
about to rupture, or an empyema to discharge, do we note redness or 
other change in hue of the surface of the prsecordia, not observed over 
the remainder of the thoracic surface. 

The Arteries. By inspection we may be able to determine pulsa- 
tion or any undue swelling or other change in the course of the vessels. 
With the exception of pulsation in the carotids, which may temporarily 
increase under excitement, pulsation of the vessels is not usualy seen 
in health. In old people we can see the pulsation of the aorta (rarely) 
at the episternal notch, and often in others, the temporals, the innomi- 
nate, the carotids, the subclavians, the brachial and radial arteries, the 
abdominal aorta in thin subjects, the femoral arteries and the posterior 
tibials. 

The Arteries ix the Neck. Temporary pulsation of the carotid 
arteries from excitement has been mentioned. It is commonly seen 
in ansemia, and is quite marked in exophthalmic goitre. It is striking in 
aortic regurgitation. It often attends the vascular changes of old age. 
It may be due to atheroma or aneurism. It is always suggestive of 
aortic valvular disease. The innominate artery, as well as the carotids, 
often pulsates visibly in the neck, and may be so large as to simulate 
aneurism. The subclavians may pulsate for the same reasons ; they 
may also be seen to pulsate if the lungs are consolidated or shrunken 
by disease. If the patient is young, the throbbing is more likely to be 
of neurosal or hseniic origin. In later life, if such pulsation is asso- 
ciated with a more or less defined swelling or tumor, with other phys- 
ical signs of aneurism, that disease is doubtless present. 

The Thoracic Aorta. An impulse of the thoracic aorta is usually 
from aneurism. The pulsation is not always due to disease. The aorta 
may be pushed against the chest- wall, or the lung-structure which over- 
laps it normally may be withdrawn. 

Tumor. An enlargement or swelling in the course of the aorta may 
be due to aneurism of that vessel. It must be distinguished from 
the tumor of mediastinal disease, and of empyema. 

The Abdominal Aorta. Pulsation of the abdominal aorta is 
often the cause of serious distress. The violent throbbing keeps the 
patient awake at night, and makes him more and more nervous and 
irritable. The pulsation is usually seen in the epigastrium. It is 
more frequent when the vessel is not diseased, in neurasthenic subjects. 
It occurs reflexly in patients with dyspepsia or organic disease in the 
upper abdominal tract. The shock of the pulsation is transmitted to 
the hand with considerable violence. The impulse is diffused, but 
not expansile. 

Epigastric pulsation also may be due to the transmission of the im- 
pulse of the aorta by enlargement of the pancreas, or tumors of the 
stomach or the omentum. The transmitted pulsation is distinct. The 
impulse is a transmitted one when the tumor can be defined and when 
a sensation of lifting is transmitted to the hand. The physical signs 
of aniiirism are absent. If the patient lies on the abdomen, or in the 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 597 

knee-chest position, the tumor falls away from the aorta, and the im- 
pulse is not readily transmitted. Epigastric pulsation is also caused 
by aneurism of the abdominal aorta. The pulsation is distensile or 
expansile, and the aneurismal sac can be defined at times. The other 
physical signs of aneurism are usually present — namely, thrill, dulness 
over the tumor, a murmur on auscultation. In these conditions, how- 
ever, we cannot always rely on the physical signs alone ; the history 
of the subjective symptoms and of disease of other structures must be 
carefully inquired into. Aneurism rarely occurs without some evi- 
dence of arterial sclerosis or some physical effect upon the circulation. 
Accentuation of the aortic second sound, variations in the femoral 
pulse, high arterial tension, and the usual evidences of sclerosis favor 
aneurism. While functional epigastric pulsation usually occurs in 
neurotic subjects, and, hence, in the earlier periods of life, yet such 
pulsation is frequently seen at the climacteric and in the neurasthenia of 
old age. Late in life, with such impulse, fibrous thickening about 
the pylorus, or contraction of the omentum, may easily be confounded 
with malignant disease. Cancer of the stomach has been diagnosticated 
under these circumstances when the pulsation was simply reflex from 
chronic gastritis. Some time ago a private patient in the Presbyterian 
Hospital had extreme pulsation of the abdominal aorta, with great 
local discomfort, on account of the throbbing. She was sixty-five years 
of age, and had within the past two years nursed her son through 
tuberculosis. She failed in health, and came to the hospital emaciated, 
with some chronic gastritis and diarrhoea. On examination, a distinct 
tumor was felt above the umbilicus, which she had been told was due 
to carcinoma. It was hard and painless ; the physical signs of aneurism 
were not present ; the pulsation was extreme. A second tumor, not so 
large, was felt in the right hypochondriac region. Both tumors were 
dull upon percussion and surrounded by tympanitic areas. They were 
also movable. While it was impossible to be sure of the nature of the 
tumors, it seemed to me they were tuberculous, or simply fibrous, and 
would not influence the patients immediate welfare. Under treat- 
ment, the pulsation disappeared ; the gastro-intestinal symptoms were 
relieved entirely ; the patient rapidly gained in weight and strength ; 
the tumors continued, but they are not so distinctly outlined because 
the previously scaphoid abdomen has become distended (two years 
under observation). The questions arose for decision : Was the epi- 
gastric pulsation due to a throbbing aorta or transmitted by an ob- 
scurely defined probable tuberculous mass in that region ? No doubt 
it was the vessel alone that caused the impulse. The diagnosis must 
be made by carefully weighing all concomitant circumstances and phe- 
nomena that surround cancer. (See Symptomatology of Morbid Pro- 
cesses.) Fecal accumulations in the colon may be made to heave by 
the beat of the aorta and cause exaggerated epigastric impulse. The 
bowels must be emptied before definite conclusions are arrived at. 

An epigastric impulse due to one of the above-mentioned causes 
must not be confounded with the impulse of hypertrophy of the right 
ventricle, or to the shock of the hypertrophied heart transmitted to 
the left lobe of the liver. In hypertrophy of the right ventricle or 



598 SPECIAL DIAGNOSIS. 

dislocation of the heart from disease within the chest, the impulse may 
be seen to the right or left of the xiphoid cartilage. The symptoms 
and signs of right-ventricle hypertrophy explain the pulsation. 

The Smaller Arteries. By inspection of the arteries beyond 
the abdominal aorta we can often recognize more distinctly the condi- 
tion known as arterio-sclerosis. Examination of the femoral, poplit- 
eal, tibial, brachial, and radial arteries reveals dilated, tortuous, hard, 
often pulsating vessels in endarteritis. Elongation of the artery, so 
that instead of a straight tube it becomes a sinuous canal, turning 
and twisting at short intervals, is seen. (See Arterio-sclerosis.) But 
pulsation of the above-mentioned peripheral arteries may be due to 
other causes. In hypertrophy of the left ventricle arterial pulsation 
is prominent, although more marked in the vessels near the heart, as 
the carotids. In regurgitation at the aortic orifice, pulsation is also 
frequently seen. 

Capillary Pulse. The capillary pulse is seen under the finger- 
nails or in the skin after hyperemia is induced by firmly stroking the 
skin with the nail. It may be seen inside the lips, if a piece of glass is 
pressed against them. There is rhythmical pulsation of the capillaries, 
from which the surface becomes alternately white and red. It is a 
sign of aortic insufficiency. 

The Veins. Diseases of the veins are largely surgical and do not 
frequently come under the notice of the physician. Alterations in the 
veins from physical causes in the circulation, local or general, are of 
frequent occurrence, and are of the greatest diagnostic significance. 
The " venous phenomena " are physiological and pathological evidences 
of the circulation of the blood in the veins. 

Examination is limited largely to the jugular veins in general affec- 
tions of the circulation ; to other subcutaneous veins in addition in 
local affections. The examination is made by inspection, to determine 
the size and degree of pulsation of the veins ; by palpation, to confirm 
the results of inspection and to determine the presence of a thrill ; by 
auscultation, to determine the presence of murmurs. 

By inspection we note the presence of : A. Enlargement of the veins. 
The change in size may be general or local. In both instances there 
is interference with the venous return of blood. 

1. General enlargements may be observed in all the veins, but 
is more readily studied in the jugular reins of the neck. Associated 
with the enlargement, general venous engorgement is observed, and 
hence oedema (which obscures external veins), cyanosis, effusions in 
serous cavities, and congestion of internal organs attend the pathologi- 
cal venous phenomena. It must follow that a central disturbing influ- 
ence upon the circulation is present, and so we find interference with 
the circulation in the right heart to be the causal factor. This inter- 
ference is due to dilatation of the right auricle and ventricle, which in 
turn may have arisen from valvulitis, myocarditis, pericarditis, or, on 
account of increased pulmonic blood-pressure, from emphysema and 
other pulmonary obstructions. In rare instances pressure upon the 
cavae by a mediastinal tumor may cause general over-fulness of the 
veins. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 599 

The jugular veins, both internal and external, are seen to be dis- 
tended, even in stout people. The observation can better be made by 
viewing the head when it is turned to the opposite side from the vein 
which is under examination. The external jugular can almost always 
be seen ; the internal jugular frequently when engorged. They may 
also be felt under these circumstances. The position of the veins can 
be more readily distinguished by observing their relation to the sterno- 
cleido-mastoid muscle. The inter oal jugular vein is seen in the inter- 
sterno-cleido-mastoid fossa, just behind the sterno-clavicular articula- 
tion. Here the jugular bulb is seen, and at this point in the veins 
the bulbar valves are situated. When abnormally full it may project 
beyond the surface and rise one-fourth or one-half inch above the 
articulation. The over-fulness is more marked in the dorsal than in 
the upright posture. 

Local Enlargements. Local increase in fulness of the veins is due 
to narrowing or closure of the venous trunk by pressure or by throm- 
bosis. A mediastinal tumor pressing upon the cava will cause abnor- 
mal fulness of the jugulars. The veins of the scalp become distended 
and tortuous in thrombosis of the longitudinal sinus. Enlargement 
of the veins of the arm or leg points to compression or thrombosis 
of the axillary or femoral vein respectively. The enlargement is 
associated with oedema of the respective extremity. Enlargement of 
the superficial veins of the thorax is seen in intrathoracic pressure 
from tumor or aneurism, rarely in dilatation of the heart. En- 
largement of the veins of both legs may be due to obstruction of 
the vena cava or both iliac veins. The latter is liable to occur in 
pelvic tumors. When there is engorgement of the portal vein collat- 
eral circulation is frequently carried on through the abdominal veins. 
The veins are enlarged ; and, in some instances, the veins about the 
navel enormously distended, because of a permanent patulous umbilical 
vein. The crown of veins — caput Medusae — is significant of cirrhosis 
of the liver and of pyelo-thrombosis. Enlargement of the veins of 
the extremities, from the causes above mentioned, must not be con- 
founded with the unilateral or bilateral varicosity that occurs during 
and after pregnancy, after prolonged intra-abdominal pressure from 
other causes, or in inflammation of the veins in the course of septic 
diseases, as typhoid fever. 

B. Pulsation of the veins. The circulation in the veins differs from 
that in the arteries. The blood-flow is continuous. Two circumstances 
modify it — respiratory movements and cardiac action. 

Pulsation due to Respiratory Movements. The modification is par- 
ticularly seen in the veins of the neck. During inspiration all of the 
veins empty rapidly, while in forced expiration, or with strong effort, 
as seen in coughing, the discharge from the veins is checked and 
they become full and even over-distended. When the fulness of the 
veins is normal the respiratory alterations are not observed, except 
the swelling that occurs in severe coughing, as in whooping-cough. 
When they are abnormal, as from right-sided cardiac dilatation (q. v.), 
they show a corresponding to-and-fro swelling synchronous with respi- 
ratory movements. Upon coughing, the jugular bulb may appear as 



600 SPECIAL DIAGNOSIS. 

a rounded pulsating bunch between the heads of the sterno-mastoid 
muscle. The internal jugular may also swell and contract. Increased 
pulsation with fulness of the veins is seen during the labored expira- 
tion of asthma and emphysema. 

Alteration of the respiratory movements of the veins is observed in 
cases of pericarditis or of mediastino-pericarditis. Normally the vessels 
are drawn upon and bent during the act of inspiration — inspiratory 
collapse. In the above pathological conditions they swell up in inspira- 
tion and empty during expiration, directly opposite to the normal state. 

Pulsation due to Cardiac Movements. The Venous Pulse. The car- 
diac movements also modify the movements of the blood in the veins. 
They cause rhythmical pulsation, or the venous pulse. This may be 
communicated from the carotids underneath or occur in the veins. 
The so-called true and false pulses are thus produced. The true venous 
pulse is divided into the (1) negative and (2) positive pulse, the former 
being the pulse of health, the latter the pathological venous pulse. 

1. The normal or negative venous pulse is so designated because it is 
not due to positive action of the heart, causing retrogression of blood. 
It can be demonstrated by pressure of the finger on the middle of the 
veins. Pulsation ceases below because the blood does not regurgitate 
from the heart ; it does not pulsate above, or the pulsation lessens 
materially, indicating non-transmission from the carotid. The negative 
venous pulse is presystolic in time, and can only be seen in the external 
jugulars. The vein collapses during the systole and distends or pul- 
sates before the systole, hence is presystolic. This may be observed 
by inspection, keeping in view also at the same time the apex or 
carotid pulse. The systolic collapse occurs quickly. The presystolic 
pulsation follows slowly, with an appreciable interval between the 
two. The presystolic distention occurs during the time that the auri- 
cle is filled with blood ; the collapse occurs w T hen the auricle is empty 
— that is, during the ventricular systole. When the auricle is dis- 
tended the flow of blood from the veins is impeded, and hence the 
jugulars are overfilled. When the auricle is empty the flow of blood 
from the veins is favored, hence the vein collapses (the systole). 

Diagnosis It may be distinguished from pulsation in the artery 
by the time, by the greater size of the surface-pulsation on account 
of the greater size of the vein, by the impression of undulation rather 
than shock received by the finger, by the impression of passive force 
rather than of active power. Sometimes it is extremely difficult to 
recognize the normal or negative venous pulse on account of undula- 
tions in the veins produced by the blood-flow and transmitted carotid 
i mpulse. 

2. The positive venous pidse is systolic in time. It is due to positive 
action of the heart. It is pathognomonic of tricuspid regurgitation 
(q. v.). When the right ventricle contracts the regurgitant blood- 
wave is transmitted into the cava through the incompetent valves. 
It appears first in the internal jugulars or their bulbs, because of the 
direct course of the innominate and right jugular from the cava. Sub- 
sequently the left may become affected. If the valve in the vein is 
competent, the systolic regurgitant wave is seen there only. The pul- 



DISEA SES OF HEART, BL OD VESSELS ANB MEDIA STIN U3I. 601 

sation of the enlarged bulb is seen in the inter-sterno-cleido-mastoid 
fossa. Usually the valve is insufficient, or rapidly becomes so, and 
the systolic back-wave therefore extends upward. The same wave is 
transmitted to the viens of the liver, causing systolic swelling and dias- 
tolic collapse of the liver. These conditions are produced, as pre- 
viously mentioned, in right-sided dilatation of the heart, providing 
there are moderate force and sloAvness of the heart's action. When 
the heart becomes very weak and rapid the pulsations disappear. 

Diagnosis 1. The negative, true, or normal pulse is distinguished 
from the pathological or positive pulse, and from the transmitted pul- 
sation, by its time. It is timed by the apex-beat, or the carotid pulse 
of the opposite side. The negative pulse (normal) is presystolic, the 
collapse of the vein systolic ; the positive pulse (pathological) is sys- 
tolic in time. The patient should hold his breath, as increased respi- 
ratory movement will modify the venous pulsation. 2. The imparted 
or false pulse is transmitted from the carotids, and can be recognized 
by stopping the flow of blood by pressing the finger or barrel of the 
stethoscope on the vein in the middle of the neck, after it has been 
emptied by pressure upward. If the pulsation is communicated (false 
pulse), the vein remains empty in the portion nearest the heart, and 
fills up in the peripheral portion, while the pulsation ceases toward the 
centre (below) and increases in the periphery (above the finger). If 
the carotid artery is pressed upon as near the heart as possible, the 
transmitted pulse will cease. In the positive pulse the portion near 
the heart slowly fills from below upward. 

In congenital heart disease with patulous foramen ovale the positive 
venous pulse may sometimes be seen, but is extremely rare. 

Diastolic collapse is seen in pericarditis, as observed by Friedreich. 
The collapse occurs at the time of the cardiac diastole. It is distin- 
guished from the true pulse as follows : compress the jugular vein, 
pulsation ceases above and below the seat of compression. 

Pulsation of other veins. Quincke has described venous pulse in 
the hand and back of the foot, with the capillary pulse in aortic re- 
gurgitation and in anaemia. It is probably only the arterial pulse 
propagated through the capillaries. The positive pulse may be seen 
in the veins of the face, in the cutaneous veins of the arm and hand, 
and in the superficial mammary veins, and in the veins of the legs. 

Palpation. The Heart. Palpation confirms inspection as to the 
shape of the prsecordia, the position and the extent of the impulse, and 
the condition of the intercostal spaces. In addition, we determine by 
palpation the character and strength of the impulse, and the presence 
or absence of valve-shock and of thrills or of friction. Palpation also 
reveals oedema of the surface and fluctuation. 

The Impulse. In a normal chest with moderate walls a slightly 
prolonged, moderately strong shock is transmitted to the hand when 
placed over the prsecordia. It is synchronous with the cardiac and 
precedes the radial pulse. It is, therefore, systolic in time. It is 
stronger when the patient leans forward, exhales freely, removing the 
lung from the surface, and when the chest-walls are thin ; it is weaker 
in opposite conditions. 



602 



SPECIAL DIAGNOSIS, 



Character and Strength of Impulse. A. Strength increased. 1. 
Overaction. In the violent action of the heart that attends palpita- 
tion, and in the increased action in the early stages of fevers or of in- 
flammation, the force of the cardiac impulse is much increased. 2. 
Disease, (a) Alterations outside of the pericardium. Increase in the 
extent of the impulse is attended by increased strength when the heart 
is hypertrophied or the lung retracted, (b) Alterations within the peri- 
cardium. In pericardial adhesions the heart is held more firmly 
against the wall and may give the appearance of strength to the im- 
pulse, (c) Disease of the heart. True increase in force of the impulse 
is seen in disease of the heart. When the organ is hypertrophied or 
the seat of dilated hypertrophy the force of the impulse is increased, 
sometimes to an almost unbearable degree. Uplifting of the precor- 
dial area or even of the lower half of the anterior part of the chest is 
seen. The hand or the head laid over the heart is forcibly lifted with 
each systolic contraction. This great force is most pronounced in 
the enormous hypertrophy that occurs in cases of aortic obstruction. 
It is the impulse and force of the so-called cor bovinum. In dilatation 
the impulse is diffused and wavy. 



Fig. 153. 




Abnormal palpable impulse and thrills. 
1. Diastolic impulse palpable from closure of pulmonic valve. 2. Presystolic impulse in mitral 
obstruction in third, fourth, and fifth interspaces. 3. Thrill at aortic orifice ; systolic, obstruction ; 
diastolic, regurgitation. 4. Thrill at pulmonary orifice ; systolic, obstruction ; diastolic, regurgi- 
tation. 5. Thrill at mitral orifice ; systolic, regurgitation ; diastolic, obstruction ; presystolic, ob- 
struction. 6. Thrill at tricuspid orifice. 

B. Strength lessened. This occurs from causes which diminish the 
extent of the impulse or cause it to be absent entirely, as when mate- 
rial intervenes between the heart and the chest-wall, or the heart 
is weakened by disease. Hence (following the classification above) (a) 
in emphysema of the lung ; (b) in pericardial effusions ; (c) in fatty 
heart, or myocarditis, in dilatation, and simple weakness of the heart, 
the strength of impulse is lessened. 

Valve-shock. The shock of the closure of the valves can be felt 
by the hand when placed evenly over the prsecordia. The shock from 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 603 

the pulmonary and aortic valves is best transmitted. It is felt most 
distinctly in persons with thin chest-walls, and when there is height- 
ened tension either in the aorta or pulmonary artery. The shock 
follows the impulse. It may be localized more accurately with the 
finger-tips in the third or fourth interspace along the left edge of the 
sternum. The shock of the auriculo- ventricular flaps is also trans- 
mitted. The shock is synchronous with the first sound. It is felt in 
the left fourth interspace near the sternum, sometimes over it. It is 
due to dilatation of the heart, and is more readily felt in thin-chested 
persons. 

Thrills. A thrill is produced when the blood is thrown into 
vibration by passing over a rough surface. It may be created with 
the systole or during the diastole. It can only be created at the time 
blood is passing through the orifices. 1. The most common seat of 
the thrill is the apex. If the hand is placed in close proximity to the 
surface of the chest at this point, a vibration or tremor is transmitted 
to it in most cases of mitral obstruction. The blood is passing from 
the auricle to the ventricle ; as this takes place before the systole, the 
thrill is felt before the impulse or carotid pulse. It is presystolic in 
time. It is sometimes difficult, however, to distinguish it from the 
impulse. Its character cannot well be described. The hesitating, 
jogging maimer of the vibrations or the thrill is clearly transmitted to 
the hand. 2. The next most frequent seat of thrill is the second costal 
cartilage on the right. Here the thrill or vibration is systolic in time 
and is caused by obstruction at the aortic orifice. It may be felt away 
from the heart, in the aorta, or in the carotids. The aortic cusps are 
thickened, contracted, and stiffened by a sclerotic endocarditis, or the 
orifice is occluded by valvulitis. 3. Sometimes a thrill is felt at the 
apex with the systole — -first sound. This occurs rarely, but must not 
be confounded with the before-first-sound thrill. It is never so dis- 
tinct, and is not made up of a series of vibrations. It is due to re- 
gurgitation at the mitral orifice. 4. Rarely a thrill is felt at the second 
costal cartilage on the right, with the second sound. It may be felt 
along the course of the sternum also, and is due to regurgitation 
through the aortic orifice. The systolic thrill must not be confounded 
with the thrill elicited over the aorta or at the aortic cartilage, which 
is due to aneurism. 5. At the second costal cartilage on the left a 
thrill is sometimes felt. It is systolic in time and is not transmitted. 
It is due to obstruction at the pulmonary orifice. 6. At the lower 
portion of the sternum a thrill systolic in time is also felt, due to tri- 
cuspid regurgitation. Care must be taken not to confound the above- 
mentioned thrills with those due to aneurism. (See Aneurism.) 

Pericardial Friction. In addition to the thrills, a friction or 
to-and-fro rubbing is transmitted to the hand in cases of pericarditis, 
in the first stage. The friction may be felt all over the heart region, 
but is pronounced in the third or fourth interspace. It may be de- 
tected on slight pressure or only when the tips of the fingers are pressed 
firmly against the interspaces. 

It is important to remember that the position of the patient weakens 
or modifies the thrill or friction. When the patient is lying down it 



604 SPECIAL DIAGNOSIS. 

may not be felt. The upright posture or leaning forward makes it 
evident, and hence the patient should be instructed, if possible, to 
assume this position in the examination. 

The Arteries. The results of inspection are confirmed. In addi- 
tion, the artery is examined, to determine its tension, the character of 
the coats, and the presence of thrills. Pulsation of organs. It is said 
that in aortic regurgitation an arterial liver-pulse, similar to the venous 
liver-pulse, can be felt when the hands are placed over that organ. 
Similar pulsation may be felt in the spleen. 

In examining the arteries it is important, as will be detailed in the 
chapter devoted to the pulse, to compare the arteries of the two sides. 
Often the pulse-wave is found to be unequal in force, in volume, and 
in time. This is almost always due to obstruction to the passage of 
the blood. When not due to endarteritis or to aneurism, it is due to 
the pressure of a tumor on the vessel somewhere in its course. A 
thrombus or embolus in the artery may likewise cause the condition. 
A difference in the radial and the femoral pulse points to obstruction 
in the thoracic or abdominal aorta. Anatomical variations must be 
remembered. 

The Pulse. The pulse is an index to the force, frequency, and 
rhythm of the heart's action and of the pressure, or tension, which is 
maintained in the arteries. 

General Observations. The frequency of the pulse before birth 
is from 120 to 140 beats in the minute. From this time it is dimin- 
ished in frequency up to adult life, 72 being then accepted as an aver- 
age ; the number of beats, however, is often under 72, and sometimes 
over that. In old age the pulse-rate is again increased. Sex has some 
influence. The rate is slightly higher in females than in males of the 
same age. 

The frequency of the pulse is subject to diurnal variations, at times 
corresponding with the diurnal rise and fall of temperature. The rate 
will, therefore, be highest in the afternoon and evening and lowest in 
the early morning hours. 

The position of the body has also a modifying influence. The pulse 
is more frequent when a person is standing than when he is sitting, 
and more frequent when he is sitting than when he is lying doAvn. 
Walking, running, bodily and mental exertion, fear, and excitement 
all tend to accelerate the pulse. 

During and for one or two hours after a meal the pulse-rate is higher, 
especially if an alcoholic or other stimulant, such as coffee, has been 
taken. 

How to Take the Pulse. To make a correct count of the fre- 
quency of the pulse, the conditions just mentioned, as normally modi- 
fying its rate, should be borne in mind. If the object of the count 
is to determine the rate which is normal for a particular individual, 
several counts will be necessary at different times and under different 
conditions, such as sitting and standing. The best time for the physi- 
cian to take the pulse will have to be determined by his own judgment 
in each case. If the patient comes to his office and is excited by the 
prospect of an examination, it will be well to wait until he becomes 



DfSEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 605 

calm. On the other hand, if he is calm at first, a count at that time 
is to be preferred to one made after the patient has been disturbed by 
a physical examination. In the same manner, on visiting a patient at 
his house, the judgment of the physician must decide whether to count 
the pulse immediately on his arrival or to postpone it until, by general 
conversation, all apprehension and alarm on the part of the patient 
have been allayed. In general, it may be said that if the physician 
finds upon his arrival that the pulse is more frequent than the condi- 
tion of the patient would lead him to expect, he should wait a while, 
endeavor to find out whether anything has served temporarily to dis- 
turb the circulation, and then make the count when the conditions are 
most favorable. Some patients are so nervous that the mere act of 
placing the finger upon the wrist sends the pulse-rate up ten or twenty 
beats in the minute. In such cases an effort should be made to obtain 
a count without the patient's knowledge by observing the pulsations 
of the temporal or carotid. In other cases it may be well to entrust 
the counting of the pulse to the nurse or to a member of the family. 
In infants and young children, count while they are asleep. In 
febrile conditions the count is more likely to be too high than too low. 

In hospital practice, or when a nurse is constantly in attendance, the 
pulse and respiration should be taken at the same time as the temper- 
ature. But the nurse must be warned against taking them under 
dissimilar conditions upon successive days. For example, the pulse 
should not be taken one day while the patient is lying down, quiet 
and comfortable, and compared with the count of the next day when 
the patient is sitting up or has jnst had some hot liquids, or a spell of 
coughing, or been subjected to some other disturbing influence. 

The preferable position is the recumbent one in the case of patients 
in bed, and in the sitting position in those not confined to bed. Care 
should be exercised in all cases to see that the patient's position is 
comfortable and that nothing obstructs the artery or interferes with 
the unimpaired flow of the blood. 

The wrist is the place usually selected at which to feel the pulse. 
At this point the radial artery passes over the radius, and can readily 
be compressed and its character made out. An old-fashioned rule 
prescribes that three fingers should be applied to the artery, the index- 
finger of the physician being nearest the heart. In particular cases it 
may be advisable to count the pulse at the temporal or carotid artery. 
The fingers should be applied so that the beats can be most distinctly 
felt. The beats are counted for fifteen seconds by the second hand of 
a watch when only an approximate count is desired, or when time is 
a factor, and then multiply by four. It is better to count the pulse 
for half a minute, and still better for a full minute. 

The arteries of the two sides must be compared. Difference in the 
force, volume, and time may be due to the anomalous distribution of 
arteries. In disease, it may occur in aneurism and atheroma, in press- 
ure on the trunk from external disease, and in embolism and throm- 
bosis. 

Condition of the Walls of the Artery. The condition of 
the artery is often of more importance than the pulse-rate. A healthy 



(306 SPECIAL DIAGNOSIS. 

radial artery, in a person not advanced in years, can be compressed 
easily against the radius without the finger being able to differentiate 
the artery from the other tissues. But as age advances, and as the 
result of certain constitutional diseases — syphilis, gout, chronic endar- 
teritis, alcoholism, and others — the artery tends to become thicker, so 
that in pronounced cases it cannot be obliterated, but is rolled like a 
cord or pipe-stem between the compressing fingers and the bone. 
Small specks or plates of atheroma, feeling like hard particles in the 
coats of the artery, may be detected. The artery has a beaded feeling. 
Fatty degeneration of the organs is likely to occur when the arteries 
are in this condition, and apoplexy is to be feared. 

Tension. Tension is the word used to express the degree of blood- 
pressure — that is, of distention of the arteries. Normally, the pulse 
nearly or quite subsides between the beats, but little pressure being 
required to obliterate it. High tension may be said to exist when the 
artery remains continuously full between the beats (Broadbent). It is 
produced by plethora ; increased heart-action ; contraction of the 
arterioles, as by chill ; and obstruction in the capillaries. The condi- 
tions which bring about obstruction in the capillaries in the order in 
which they are enumerated by Broadbent are : 1. Age. The liabil- 
ity to high arterial tension increases with the age, especially after 
middle-life. 2. Heredity. There is in some families a marked ten- 
dency to high tension. The younger members show its effects in head- 
aches and bilious attacks, while the older ones develop chronic heart 
disease and apoplexy. 3. Disease of the kidney. Parenchymatous, 
but especially interstitial nephritis, is associated with high arterial 
tension ; this, with accentuation of the aortic second sound, is one of 
the early and, therefore, one of the most valuable indications of chronic 
Bright' s disease. 4. Gout. Gout and lithsemia are almost always 
accompanied by high arterial tension. 5. Diabetes in old persons 
associated with gout. 6. Lead-poisoning. 7. Pregnancy. 8. Anaemia. 
9. Emphysema and chronic bronchitis. 10. Mitral stenosis. 

As regards arterial tension in persons presenting signs of angina 
pectoris, Sansom asserts that if the tension is increased, even though the 
signs are not typical, the fear, present or remote, of true angina is justified. 
On the other hand, if there is persistent low tension, especially during 
the painful crisis, it is almost certain the affection is a false angina. 

Loiv tension of the pulse is characterized by a softness and a com- 
pressibility in excess of the normal. This, like the high tension pulse, 
may be a family peculiarity. It is met with in conditions of great 
depression and exhaustion, and wherever there is a marked cardiac 
weakness. It is most common in fever, particularly in typhoid, in 
which also an accompaniment of low T -tension pulse — namely, dicrotism 
— is met with in a marked degree. Pat persons are apt to have low- 
tension pulses, and it may occur in any person temporarily under the 
influence of external warmth and moisture, such as a hot bath, or after 
taking hot drinks, or under the influence of depressing emotions, and 
after diarrhoea, or copious urination. 

Volume. The volume of the pulse should be noted. It is usually 
large in conditions of pyrexia and when the tension is low. A small 



DISEA SES OF HE A RT, BLOOD VESSELS A NL> MEDIA STIN UM. 607 

pulse is met with in many conditions other than weakness of the 
heart-muscles. In aortic stenosis the pulse is small , and in mitral 
stenosis it is small, of high tension, and frequently irregular. In gen- 
eral contraction of the arterioles, as happens under the influence of a 
chill, the pulse is small. In Bright's disease it is sometimes very 
small, slow, and hard. Some care will be required to differentiate such 
a pulse from a weak pulse. In acute peritonitis the pulse is apt to be 
small and hard. 

Rhythm. The rhythm of the pulse is of diagnostic importance. 
In health one beat succeeds another at equal intervals of time, and the 
successive beats are of the same force and quality. Here, also, how- 
ever, as in other conditions, there are variations within physiological 
limits. In some persons the pulse-rate is somewhat accelerated during 
respiration and becomes slower in the pauses which follow breathing. 

In disease, disturbance of the rhythm occurs as intermission or as 
irregularity. Intermission signifies a dropping of a pulse-beat ; sev- 
eral normal pulse-beats succeed each other, and then the pulse is absent 
during the time occupied by one or two beats. The intermission may 
occur at regular or at irregular intervals — that is to say, every third, 
fifth, or sixth beat may be wanting, or the intermission may be irregu- 
lar — now a second, the next time a fifth or a third beat being absent. 
Moreover, the intermittent pulse may be constant, or it may, and more 
frequently is, only occasional. It is not characteristic of any one dis- 
ease or condition, and it may exist without the patient's knowledge 
and without producing any perceptible effect upon his health. Some- 
times it is met with in a fatty heart, and this disease may be suspected 
if the intermittent pulse is associated with a weak first sound of the 
heart without valvular lesion, and evidences of failing circulation, such 
as oedema of the feet. More frequently, however, the intermittency 
is a symptom of nervous depression, or is caused by tea, coffee, tobacco, 
or digitalis. So far as prognosis is concerned, it is much less serious 
than irregularity. Broadbent says he has met with it at the age of 
eighty, when it was known to have existed for forty years. 

Irregularity is characterized by differences in time, force, or volume 
of successive beats. A full beat is succeeded by another, which is 
smaller and weaker, or successive beats occur at irregular intervals 
of time. Irregularity may or may not be associated with intermission. 
In advanced cases of mitral stenosis the pulse is both irregular and 
intermittent. The irregularity may be habitual or occasional ; the 
former is due most frequently to mitral lesions, but sometimes occurs 
without assignable cause, and is attributed to disturbance of the nerve- 
supply ; the latter is due to digestive disturbances and to the effect of 
nicotine and digitalis. Irregularity is not incompatible with health, 
but is much more likely to be of serious import than intermission. It 
occurs in diseases of the brain, in degeneration of the heart as well as 
in valvular lesions, and in grave cases of febrile diseases, such as 
typhus and typhoid, when the heart-muscle is involved. Some cases 
of Graves' disease are characterized by great irregularity instead of 
excessive rapidity of the pulse. Irregularity may occur in rheumatoid 
arthritis also, though increased frequency is the rule. 



£08 SPECIAL DIAGNOSIS. 

Frequency. The frequency of the pulse is of aid in diagnosis. 
Increased' frequency. 1. The pulse is increased in frequency in all 
the febrile diseases, and generally in the proportion of eight to ten 
beats for each degree of rise in temperature above 98.3°. But there 
are important exceptions. In typhoid fever the pulse is slower in pro- 
portion to the temperature and the gravity of the disease than in most 
of the other acute febrile diseases. It may not beat above 85 in mild 
cases, and in severe cases frequently does not rise above 100. Conse- 
quently a pulse of 120 is of much graver import than it would be in 
other diseases. It may be more frequent during convalescence than 
during the febrile stage. This pulse-rate helps to differentiate it from 
tuberculosis, malignant endocarditis, and septicaemia. 

2. The pulse of scarlet fever often aids materially in diagnosis. A 
pulse of 120 to 160 is the rule from the development of the sore-throat 
to the completion of the eruption. In measles, rubella, diphtheria, 
and follicular tonsillitis it is much slower during the early stages. 

3. In Gh'aves'' disease great frequency of the pulse is the essential 
and most constant symptom of the disease. The pulse may be con- 
stantly considerably over 100, and in attacks of palpitation 200 or 
more. In these attacks there may or may not be precordial distress 
and mental anxiety. Here belong the cases described as paroxysmal 
hurry of the heart, etc., the thyroid and ophthalmic symptoms being 
absent. 

4. Cases have been reported of extreme frequency of the pulse 
(160 to 240) without palpitation, dyspnoea, or any signs of Graves' dis- 
ease. Some of the patients have been able to perform much bodily 
and mental labor, notwithstanding that the rate mentioned was main- 
tained persistently for weeks. To this class of cases the name tachy- 
cardia has been provisionally applied until their pathology is under- 
stood. 

5. In all forms of valvular disease, except aortic stenosis with fail- 
ing compensation, the pulse may be increased in frequency. In col- 
lapse ; in weakening of the heart ; and in central or peripheral vagus 
disease, the pulse is increased. Mitral stenosis may be latent until 
great excitement, overexertion, and particularly running or forced 
inarches bring on palpitation, or simply abnormal and persistent fre- 
quency of the heart's action, with or without dyspnoea. 

6. Attention has been called, especially by Dr. J. Kent Spender, to 
acceleration of the pulse as an early symptom of rheumatoid arthritis. 
The pulse increases gradually until it reaches a range of 110 to 120, and 
it persists at that rate with little diurnal variation, even after the 
arthritic symptoms subside. 

7. In locomotor ataxia permanent moderate acceleration of the pulse 
(90 to 100) is a frequent symptom. 

8. Infections. In the puerperium increased frequency with irregu- 
larity of the pulse is a surer indication of intra-uterine mischief than 
is the temperature. So, too, in all cases of inflammation so situated 
that the products are absorbed into the circulation and not discharged 
externally, the pulse shows by its increased frequency that a septic 
process is going on. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 609 

Diminished Frequency. A slow pulse (bradycardia), under 60, like 
a frequent pulse, is sometimes habitual, and sometimes a family char- 
acteristic. Pathologically, it is met with in conditions which increase 
the resistance in the arteries, such as Bright' s disease, especially acute 
glomerulo-nephritis ; but it is especially common in jaundice. The 
bile-acids have the effect of retarding the action of the heart. 

A slow pulse is met with in certain forms of heart disease, as aortic 
stenosis, but it is not constant in any of them. It occurs in fatty de- 
generation, especially when due to obstruction, by atheroma or other- 
wise, of the coronary arteries. W. J. Pettus has reported a case of 
bradycardia associated with aneurism of the right sinus of Valsalva, 
involving the orifice of the right coronary artery. When it appears 
in the late stages of valvular affections or specific diseases with cerebral 
symptoms it is usually a sign of danger. It is seen in articular rheu- 
matism (Atkinson). According to Riegel, it is most common in con- 
valescence from acute disease, particularly pneumonia, typhoid fever, 
erysipelas, and rheumatic fever. It is also frequently encountered in 
diseases of the digestive organs and of the urinary organs, particularly 
acute nephritis. Moreover, it is generally slow in myxoedema, and both 
slow and irregular in epilepsy. It is slow, not uncommonly, also, in 
melancholia and in the early stages of cerebral meningitis and in tumors 
and cerebral hemorrhage. 

The Sphygmograph. The sphygmograph, as its name implies, is 
an instrument for recording in writing the volume, force, frequency, 

Fig. 154. 




Dudgeon's sphygmograph. 



tension, and general characteristics of the pulse. Many forms of the 
instruments have been devised since the first one of Marey. The later 
models have the advantage of simplicity and ease of application. One 
of the most convenient is Dudgeon's. It has its faults, particularly 
in exaggerating the vibrations when the pulse is large and the heart is 
acting violently ; nevertheless, with care, trustworthy tracing can be 

39 



610 SPECIAL DIAGNOSIS. 

obtained in all ordinary cases. No matter what instrument is used, 
the value of the tracing depends very largely upon the personal skill 
and experience of the one who takes the tracing ; hence the sphygmo- 
graph occupies a position very different from the thermometer and 
other instruments of precision. While it is true that a person can 
learn to detect nearly all the variations of the pulse by palpation alone, 
yet the tracing has the great advantage of permanency, and many per- 
sons are led to palpate the pulse more carefully by seeing in a sphyg- 
mographic tracing a dicrotism or irregularity which had escaped their 
attention. 

The expansile pulsation of the artery is communicated by a system 
of levers to a needle, which graphically records the qualities of the 
pulse upon smoked paper. 

Directions for Using Dudgeon's Sphygmograph. 1. Wind up, by 
the button, the clockwork contained in the box. The clockwork 
carries the smoked paper under the writing-needle. 

2. See that the patient is in a comfortable position, and have him 
hold toward you either hand w T ith wrist exposed, fingers gently flexed, 
and muscles relaxed. 

3. Apply the instrument by slipping the band over the hand, the 
free end of the band being passed through the retaining clamp. The 
metal box is placed toward the elbow. 

4. Now adjust the instrument by placing the bulging button which 
connects the levers directly over the radial artery at its most accessible 
point. 

5. Keep the instrument accurately in place with the left hand, and 
draw the band through the clamp with the right until the writing- 
needle plays freely with each pulsation of the radial artery, then fasten 
the band by screwing up the clamp. 

6. Introduce the smoked paper between the rollers and under the 
writing-needle. 

7. Vary the pressure by means of the thumb-screw, which connects 
with an eccentric, until the best apparent amplitude of vibration is 
obtained. 

8. Instruct the patient not to move the fingers or hand, and further 
steady them for him with your own right hand. 

9. Start the clockwork by pushing the bar at the top of the clock- 
work box. 

10. Allow the paper to run through, and then stop the clockwork. 
The clockwork is so regulated that five inches of smoked paper 

pass through in ten seconds, so that six times the number of pulsa- 
tions recorded on the paper represent the pulse-rate per minute. Each 
instrument, however, should be tested and its time determined. The 
clockwork should be wound up for every tracing. 

Considerable practice will be required to take a tracing rapidly and 
accurately, in spite of the simplicity of the mechanism. 

Several tracings should be taken at different pressures and com- 
pared, or, what is better, as suggested by Sansom, stop the clockwork 
and alter the pressure two or three times, so as to have the effect of 
varying pressures on one tracing. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 611 

The technique of sphygmography needs a few words. Smoked 
paper is generally used for the tracings. A paper glazed upon one 
surface and rough upon the other has some advantages. This paper 
has to be cut in strips about seven-eighths of an inch wide and six 
inches or more long. The cutting should be done with care so that 
the edges are smooth and even, otherwise the paper sticks in the in- 
strument and the tracing is spoiled. The glazed surface is blackened 
by holding it above the flame of a small piece of burning gum cam- 
phor. For convenience a strip of tin, bent upon itself at each end, so 
as to catch and hold about an inch of the ends of the paper, may be 
used to prevent the fingers from becoming blackened and to preserve 
the ends of the paper unblackened for memoranda. The blacking 
should not be too thick, otherwise the needle will not plough through 
it easily, and the white line of the tracing Avill not be distinct. After 
the tracing has been made, the name of the patient, the diagnosis of 
his disease, the date of the tracing, and the amount of pressure em- 
ployed should at once be scratched with a fine-pointed pen upon the 
blackened surface beneath the tracing, or written in ink upon the un- 
blackened end of the paper. The tracing is then ready for preserva- 
tion. This is done by dipping it into a solution of shellac or in tinc- 
ture of benzoin (gum benzoin 5j> alcohol f5vj) ; the alcohol evaporates 
and leaves a smooth, glazed surface. Dr. Dudgeon recommends as a 
varnish a solution of gum damar oj, rectified benzoline f5vj. When 
the tracing is likely to be subjected to friction, a second or third coat 
should be applied subsequently. 

Explanation of the Normal Pulse-tracing. With each contraction of 
the left ventricle a volume of blood is forced into the aorta, which dis- 
tends it, the distended impulse being transmitted by a wave-like 
motion to remote arteries. This distending impulse lifts the button of 
the lever sharply upward, forming the so-called percussion up-stroke, 

Fig. 155. 




a, b, percussion up-stroke ; a, b, e, percussion wave ; c, d, e, tidal wave ; e,f, g, dicrotic wave ; 
d, e,f, aortic notch ; /, g, diastolic period. 

a b ; but the distending impulse is exaggerated by the system of 
levers, and having been thrown up too high, the lever falls by its 
own weight too low, so that it is again caught and lifted by the tidal 
blood, forming the tidal-Avave, c d e. The gradual descent of the lever 
is again interrupted at efg, forming a wave, called the dicrotic wave, 
due to the recoil of the blood from the closure of the aortic valves. 
(Fig. 155.) 

Roy and Adami believe that the apex (h, b, d) of the percussion- 
wave is due to the sudden pulling down of the auriculo-ventricular 



012 SPECIAL DIAGNOSIS. 

valves by the papillary muscles during the first rapid part of their 
contraction. Hence they call the wave the " papillary wave." 

The second wave (c, d, e) corresponds in time, they say, with the 
outflow from the ventricle due to the continued contraction of the 
heart-wall and papillary muscles after the flaps have been pulled down. 
Hence, they prefer to call this wave the " outflow remainder," instead 
of " tidal " wave. 

Interpretation oe Pulse-tracings. Sphygmographic tracings 
must be interpreted in accordance with the known peculiarities of the 
patient, his history, and the associated physical signs. 

1. The Amplitude. The height of the percussion-stroke varies con- 
siderably in health. It is increased in conditions which bring about 
low tension and rapid systolic contraction of the heart. Hence the 
febrile pulse is usually one of considerable amplitude. It is increased 
also very markedly in aortic regurgitation. Suddenness of systole 
rather than force determines the height of the up-stroke. (See Fig. 
156). 

Fig. 156. 




Tracing from a case of aortic regurgitation. 

2. Obliquity of the Percussion-stroke. Normally the percussion- 
stroke ascends vertically from the base-line. A tendency to incline 
forward indicates a weak and laboring heart or an aneurism inter- 
posed between the radial artery and the heart. In the latter case 
there is also a tendency to rounding of the summit of the percussion- 
wave, and the up-stroke is generally short. There is usually also 
irregularity in successive pulsations, some showing the gradual ascent 
and rounded summit much better than others. Sometimes, however, 
when aneurism exists, there is no evidence of it in the tracing, and 
differences upon the two sides are not always significant. (See Fig.' 
157.) 

Fig. 157. 



Tracing from a case of aneurism of the aorta. 

Disease at the aortic orifice and the intervention of a considerable 
quantity of subcutaneous fat or of any growth superficial to the vessel 
may cause a marked obliquity of the percussion-stroke. Sansom 
asserts that, such causes excluded, as well as aneurism and organic 
disease of the aorta and its valves, a sloping line of ascent, observed 
under various gradations of pressure, indicates feebleness of the left 
ventricle. He considers it of higher diagnostic value than irregularity, 
which lie says is often neurotic. 

3. Increased Breadth of the Apex of the Percussion-ivave. The 
breadth of the apex of the percussion-wave indicates the time during 



DISEASES OF HE A RT, BLOOD VESSELS AND MEDIASTIN UM. 613 

which the artery is kept full by the systole of the left ventricle. 
When the left ventricle acts slowly and forcibly the arteries will be 
kept distended for a longer time, and this distention will be manifest 
in broadening of the apex of the tracing. (See Fig. 158.) The degree 

Fig. 153. 



SJ 




From a case of aortic stenosis, showing increased tension and the pulsus bisferiens. 



of distention of the artery is called tension, hence a broadening of the 
apex is an evidence of high tension. As the word " high " does not 
indicate the duration of the tension, Sansom has very properly sug- 
gested that we should speak of persistent high tension as " prolonged " 
tension. This, then, is the significance of the broad top of the tracing. 
(See Fig. 159.) 

Fig. 159. 



From a case of mitral stenosis, showing increased tension and some irregularity. 

Prolonged arterial tension occurs when there is a strong heart acting 
slowly, a large volume of blood, or obstruction in the capillary circu- 
lation. (For specific causes, see under Tension.) 

The amount of pressure required to develop the characteristics of a 
pulse, and, still more, the amount required to obliterate it, are good 
indexes of the degree of tension present. Some pulses, however, 
appear to the touch to be of prolonged tension, but a sphygmogram 
does not show it. Such cases are often explained by the fact that the 
heart has begun to fail under the strain put upon it by prolonged 
obstruction in the capillaries. There may be regurgitation also from 
the mitral or aortic orifice. 

4. Acute Angle of the Percussion-wave. When the heart's action is 
feeble or sudden, the volume of blood small, or the resistance in the 



Fig. 160. 




Low tension with irregularity, from cases of mitral regurgitation. 

capillaries much diminished, the up-stroke of the tracing is vertical, 
and the down-stroke forms an acute angle with it. The dicrotic wave 
is pronounced, and often descends unduly low, sometimes to the base- 
line. These are the characteristics of low tension. (See Fig. 160.) 
When the dicrotic wave springs from a lower level than the base-line 



614 



SPECIAL DIAGNOSIS. 



of the tracing it is hyper dicrotic. When the dicrotic wave is wholly 
effaced in the succeeding up-stroke it is monocrotic. 

While di erotism is commonly associated with low-tension pulses, it 
is occasionally met with also in high-tension pulses. Sansom says, 
however, that he has scarcely ever observed the conjunction of broad 
summit and marked dicrotism without the patient's manifesting the 
sign of failing heart. 

5. Irregularity of the Base-line. This occurs normally in some 
persons as the result of respiration, especially deep breathing. It 
occurs in respiratory diseases also, and in affections causing dyspnoea. 
Decided undulation of the base-line, the curves being irregular, occurs 
in tubercular meningitis. 

6. Differences in the Height of Successive Percussion-waves or in their 
Distance from- Each Other. These are written evidences of disturb- 
ance in the rhythm of the heart. The first expresses irregularity in 
volume of successive beats, and the second irregularity in time. When 
this latter amounts to the omission of a beat it is called intermission. 
All these changes are shown in Fig. 161. 



Fig. 161. 




From a case of advanced mitral stenosis, showing extreme irregularity and intermission. 



The Veins. Thrombosis. This is usually detected by palpation, 
and occurs most frequently in the femoral vein. The vein is trans- 
formed into a firm, round cord, and is distinguished from the artery 
by the absence of pulsation. Thrombosis in these veins and in the iliac 
veins higher up occurs in acute infectious diseases and in the debility 
of the aged. Dropsy in the area of distribution of the veins is per- 
ceived. 

Percussion By means of percussion the shape and size of the heart 
and changes in the area of cardiac dulness are determined. (See the 
Lungs for discussion on percussion.) To determine the size of the 
heart, both superficial or light, and deep, or strong, percussion must be 
employed. By the former we determine the area of superficial or 
absolute cardiac dulness ; by the latter, the area of deep cardiac dulness. 

1. The Area of Superficial or Absolute Cardiac Dulness. 
(See Plate XVI.) It is the area not covered by the lung at the time 
or inspiration. The lungs overlap the heart, and, in inspiration, allow 
a small area to be in contact with the chest-wall. The percussion-force 
employed must be light, so as not to elicit the resonance of the extreme 
thin edge of the lung. The area extends from the fourth to the sixth 
costal cartilages. The right border may be roughly defined by a line 
drawn along the left edge of the sternum from the upper border of the 
fourth rib downward ; the left border by a line extending from the upper 
border of the fourth rib at the left edge of the sternum to a point 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 615 

midway between the parasternal and the mammillary line in the fifth 
interspace. The lower border is continuous with liver dulness. 

Method. The right border is determined by percussing from right 
to left toward the median line. Always begin to percuss far enough 
from the heart to get the clear pulmonary note. To insure uniformity, 
select a definite area from which to start in all cases. Apply the 
finger vertically at first. The right border may correspond with a 
line outside of or along the right edge of the sternum, with the median 
line or the left edge of the sternum, or even beyond the latter. After 
the edge of modified resonance is reached, percuss with the finger par- 
allel to the ribs, to control the result previously secured, and as each 
interspace is percussed the upper limit of liver-dulness and the tri- 
angle (Ebstein's) between the liver and heart may be determined. 

The left edge is determined by percussing in vertical lines from a 
point near the axilla toward the heart. Opposite the second and third 
interspaces the aorta on the right side, and the pulmonary artery on 
the left, will cause impairment of the normal pulmonary resonance. 
The student should acquire the habit of proceeding from definite fixed 
positions toward the heart, and to observe the changes during inspira- 
tion and expiration. The lower border and rounded apex of an en- 
larged heart cannot be defined if the stomach contains food or fluid. 
It is triangular in shape, with the apex pointing downward. 

The cardio-hepatic triangle is the more or less resonant area in the 
right fifth interspace which separates the right heart and the liver. 
The apex of the triangle points to the sternal edge, the base to the 
axilla. The upper side corresponds to the right border of the heart ; 
the lower is the upper limit of the liver. 

Changes in Size. The superficial area of dulness or absolute dulness 
is increased in pericardial effusion in enlargement of the heart and 
when the heart is pushed against the chest-wall. It is replaced by 
resonance in emphysema, and hence absent entirely, as the lung over- 
laps or completely covers the heart. It is absent when the heart is 
drawn under the lungs by adhesions and when there is air in the 
pleural or pericardial sac. 

Absolute Dulness Increased. The increase in the area of abso- 
lute dulness in all directions occurs in hypertrophy of the heart and in 
pericardial effusions. The increase in width at the base of the heart 
occurs in dilatation, pericardial effusion, and aneurism of the aorta. 
Change in the position of the heart, a general idea of which is obtained 
by inspection and palpation, always changes the shape and extent of 
the dulness. The heart should be accurately delimited when displace- 
ments have taken place. 

Increase of Dulness Upward. In addition to general increase 
in cardiac dulness, one of the boundaries or a portion of the boundary 
may be increased or extended beyond the normal line. Thus the area 
of dulness may extend upward. It may be followed by extension of 
the right and left boundaries. The relative area of dulness is abol- 
ished. The change from pulmonary resonance to dulness is abrupt and 
decided. The area of dulness becomes pyramidal or pyriform in shape. 
It is due to effusion in the pericardium. Upward increase of dulness 



61 (J SPECIAL DIAGNOSIS. 

may be due to disease of the vessels. Increase in the area of dulness 
over the bloodvessels is usually due to aneurism. It may be general, 
as in dilatation of the aorta, or local, as in aneurism. Extension of 
the d ulness outward or upward from the normal line may be found at 
the right of the sternum (aneurism of the ascending aorta), or over the 
first bone of the sternum (aneurism of the transverse aorta), or to the 
left just above the cardiac area. In the last case the dulness is an 
extension upward of the normal area of cardiac dulness with rounding 
of the area affected ; the aneurism is situated at the beginning of the 
aorta. 

Increase to the Left. Increase in dulness to the left occurs in 
enlargement of the heart from hypertrophy or dilatation. If the dul- 
ness extends outward to the left and retains the triangular shape, with 
the apex pointed, it is due to hypertrophy of the left ventricle. If, on 
the other hand, it becomes quadrilateral in shape, with the apex 
rounded, it is due to dilatation of the left ventricle. The results of 
palpation and inspection aid- in detecting the presence of one or the 
other of the two conditions. 

Increase to the Right. The area of dulness extends to the 
right. It is due to hypertrophy and dilatation of the right auricle and 
ventricle. If the auricle is dilated, the right edge is extended beyond 
the normal in the third and fourth, or as high as the second interspace. 
With this increase in dulness there are also seen an epigastric impulse, 
venous turgescence, and pulsation of the veins of the neck or of the 
liver. 

Deep Cardiac Dulness. Many authorities consider the deep or 
relative area of cardiac dulness of importance in diagnosis. The percus- 
sion must be strong. The best method is that advised by Gibson and 
Russell. Their directions are as follows : " Begin in the upper left 
interspaces sufficiently far out from the sternum to secure pulmonary 
resonance. For instance, in the second interspace begin in the mid- 
clavicular line and percuss strongly. As soon as a slight alteration in 
that sound is noted, the point is indicated by a mark. The second or 
third and succeeding interspaces are percussed in like manner, bearing 
in mind that the percussion must begin further out in each interspace, 
in order to get pure resonance. As dulness is secured in each space a 
mark is made. This is continued to the apex if that is visible, or to 
the base of the chest. By joining the marks in each interspace with 
the line at the base of the heart, the left border of the cardiac dulness 
can be fixed." The authors correctly point out that in this way the 
true apex of the heart is found, enabling auscultation to be conducted 
more accurately. 

The right edge of the vessels and of the heart is defined in the same 
way. The difference in the sound, in passing from the lung to the 
heart, is not so distinct along the right border as along the left. The 
authors include the dulness which is due to the vessels at the base of 
the heart, and hence begin percussion in the higher interspaces. This 
they deem is proper, because it is impossible to delimit the two. The 
dulness of the vessels is not so marked, however, and may be indicated 
by simple change in pitch in the percussion-note. The lower border 



DISEASES OF HE A RT, BLO OD VESSELS AND MEDIA STIN UM. 6 1 7 

of cardiac dulness is ascertained with difficulty, because of its close 
apposition with the liver. At times there is a difference in the char- 
acter of the dulness between the two organs. It can be well made out 
by stethoscopic percussion. This may not be so pronounced as we pass 
from the heart to the liver in the median and parasternal lines. 
Toward the apex the difference is more apparent. 

Pleximetric Percussion. For more accurate cardiac percussion, 
Sansom recommends the use of a pleximeter designed by himself, by 
which delicate shades in dulness can be readily heard. The pleximeter 
is a thin, flat, oblong plate one inch by half an inch, which has on its 
upper surface a column rising from the middle, one and a half inches 
in height, which is surmounted by a second plate three-eighths to 
three-fourths of an inch, set parallel with the lower plate. The instru- 
ment is held between the forefinger and middle finger of the left hand, 
the sensitive tips of the fingers resting on the upper surface of the 
larger horizontal plate. The lower surface of this latter is held close 
to the wall of the chest, and percussion with one or two fingers of the 
right hand with an even and not too forcible stroke from the wrist is 
made upon the upper plate. The resulting vibrations are transmitted 
to the ear and are also appreciated by the digital sense of touch, so 
that both senses aid in the determination of the nature of the sound 
produced. 

Method. The pleximeter is placed with its long diameter parallel 
with the sternum, about midway between the axilla and the right ster- 
nal border. Percussion is made upon the summit of the column by 
one or two fingers, and the pleximeter is moved, always in parallel 
lines, nearer and nearer to the sternum. A line is reached where the 
vibrations are modified. Incline the pleximeter so that the vibrations 
come from its left edge. This edge, or line, is practically the line of 
demarcation of the dulness, and should be indicated with an aniline 
pencil. It corresponds to the outline of the right border of the heart. 
The process must be repeated at higher and lower levels until the entire 
right border of cardiac or aortic dulness is ascertained. In passing, it 
may be stated that percussing from above downward with the long 
diameter of the pleximeter horizontal instead of vertical leads to the 
upper limit of the liver as indicated by modified vibrations. At 
about the fifth right intercostal space a short curved line is thus 
made out along the right edge of the sternum, which indicates the 
outline of the right auricle at the point where it joins the liver- 
dulness. Above this, as far as the second rib, the line indicates the 
outline of the right border of the auricle and the aorta. The outline 
of the auricle may be in the mid-sternum ; of the aorta, at the right 
edge. In percussing the left side of the chest the same method is 
adopted. Begin at the level of the second rib, two or three inches 
beyond the left edge of the sternum, and move to the right. Join the 
lines of modified vibrations, and in this manner the left border of car- 
diac and aortic dulness is secured. The outline of the apex of the 
heart is readily mapped out. Over the tympanitic stomach light per- 
cussion is necessary. To narrow the area of percussion about the apex, 
the percussion may be performed on the larger plate, while the smaller 



618 SPECIAL DIAGNOSIS. 

is applied to the chest. The vibrations over the liver and over the 
right ventricle are difficult to distinguish, although sometimes so differ- 
ent that demarcation of the border of the ventricle presents no difficulty. 
Between the apex of the left ventricle and the left lobe of the liver the 
space is easily marked out. 

A correct outline of the heart and of the vessels is thus obtained. 
The upper limit of dulness is formed by the right auricle, the aorta, 
and the pulmonary artery. Any bulging or undue expansion is due 
to aneurism or aneurismal dilatation ' of the aorta. The space be- 
tween the apex and the left lobe of the liver defines the lower border. 
Sansom points out that by this method of percussion the following 
absolute data can be obtained : " A projection to the right of the area 
of the upper part over the second and third interspaces points to aneu- 
rism of the aorta or of the innominate artery. It may be traced to the 
left side of the sternum, on account of saccular dilatation of the aorta. 
If the dulness at the upper part extend greatly to the left, an increase 
in size of the pulmonary artery may be suspected. Along the mid- 
sternal region, extension beyond the right side joining the line indi- 
cating the upper border of the liver indicates distended inferior cava. 
This distention occurs in right-sided dilatation of the heart, and the 
dulness may also be due to dilatation of the adjoining auricle. The 
outline of dulness obtained over the apex of the heart, if pointed, indi- 
cates hypertrophy ; a more rounded outline shows dilatation. In un- 
complicated hypertrophy the line of the right ventricle forms a much 
less obtuse angle with the liver-dulness than in dilatation. Of great 
diagnostic value is the diminution of the area of dulness from atrophy 
of the heart as observed in wasting, as in cancer, and in tuberculosis ; 
it may also be observed in typhoid fever. In the above-mentioned 
conditions it is a bad prognostic sign." 

Adjacent Dulness. Care must be taken not to confound the 
dulness of pleural effusion or consolidated lung with the cardiac 
dulness. 

Kepercussion. Modification of the vibrations felt by the fingers 
on the pleximeter, as pointed out by Sansom, may indicate an abnormal 
change in physical condition impossible to detect in any other way. 
It is to be remembered that over the lungs the vibrations are exces- 
sive ; over solid structures they are modified or lessened. Now, the 
change from vibrations to absence of vibrations may be gradual or 
abrupt. Sansom determines this by percussion, after the heart has 
been outlined in the above-mentioned manner. In percussing from 
the lung to the heart area, if the modified vibrations occur abruptly, 
it is very probable that there is pericarditis with effusion or thickened 
pericardium ; or if, on percussing from above downward, there is 
pericardial effusion, no vibrations are to be elicited over the area de- 
limited — that is, the absence of vibrations is noted over the whole 
area — whereas, in ordinary conditions, when the pericardium is unaf- 
fected, in percussing from above downward over the area which had 
been delimited on the right and left sides respectively, a line will 
be reached where the vibrations become modified. This line com- 
mences a little above the ensiform cartilage and inclines toward the 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 619 

left border of the cardiac dulness at the level of the fourth rib and 
third interspace. Vibrations are more marked above than below the 
line. The line at which the lessened vibrations begin points out the 
commencement of the thick wall of the ventricles ; the portion above 
(more vibratory) indicates the position of the right auricle and vessels. 
If the pleximetric percussion is employed, areas of superficial and deep 
dulness need not be estimated. 

The Apex Impulse. Whichever method of percussion is em- 
ployed, it will be often observed that the spot marked by inspection 
and palpation as the apex impulse is far outside of the left border of 
cardiac dulness. In hypertrophy of the left ventricle it may be a con- 
siderable distance to the left. In dilatation the difference is not so 
marked. The percussion-lines are made when the heart is away from 
the chest, and henCe are within the systolic apex-beat. 

Method of Graphic Record. (See also page 536.) We are indebted 
to Sansom and Ewart for a method of recording the outlines of the 
areas of dulness and the position of the apex-beat and other pulsations, 
which is of great value for class-demonstration, and for permanent 
records to compare with other records taken from time to time. The 
points of pulsation and border-lines of dulness are marked by a derma- 
tographic pencil. Various colors may be used in order to indicate the 
different data. The landmarks, etc., are outlined by a camel' s-hair 
pencil dipped in olive oil. The episternal notch, the clavicles, the 
intercostal spaces, the ensiform cartilage and nipples, etc., the percus- 
sion-outlines, and other recorded marks are passed over with the oiled 
pencil. A sheet of tissue-paper, or of copying-paper, is then gently 
placed over the whole, so that the oil-marks are imprinted. After the 
paper is removed the oil-outline is colored with the dermatographic 
pencil, and a permanent record is preserved. By this plan of record- 
ing a maximum of precision is attained. Outlines can be measured 
and positions defined by mathematical data. The name of the patient, 
the date of observation, with a brief history of the case, should be 
attached to the chart. If the colored pencil-marks on the patient's 
chest are objectionable, the outline may be made with the colorless 
oil-pencil at the various steps of the examination. After they are trans- 
mitted to the paper they may be made more distinct with the colored 
pencils. Packard fits to the chest a square of coarsely woven muslin 
and outlines the ribs and sternum, etc., which are seen through the 
meshes. With colored pencils, dull areas, etc., the site of organs, the 
position of murmurs, are then designated. 

Ewart has shown that after long intervals the size of the chest and 
abdomen is apt to alter from various circumstances — growth, muscu- 
lar development, habit of sitting, etc. He therefore points out the 
advisability of using the sternum, which is immovable, for the sake of 
future comparison. 

Sense of Resistance. Ebstein delimits the heart by the sense of 
resistance, change in size being noted by increase or diminution of the 
area, which in health gives a sense of resistance to the percussing finger. 

Auscultation. Method. Either method of auscultation may be 
employed. By the immediate method we may form a general notion 



620 



SPECIAL DIAGNOSIS. 



as to the condition of the heart-sonnds. The mediate, however, is pref- 
erable, because it is essential to localize the sounds that are heard, and 
because, if the double stethoscope is used, we can percuss the cardiac 
area. The patient should be in a comfortable position. The muscles 
should not be strained. The general directions for performing auscul- 
tation must be followed. Before he begins the observer has, if pos- 
sible, determined the presence of the impulse, or found the radial or 
carotid pulse. By this means the time of the heart is taken and the 
relation of the events of the cardiac cycle to each other is ascertained. 
With each normal impulse or carotid pulse a systole takes place ; hence 
they are synchronous. The systole occurs just before the radial pulse. 

By auscultation we determine (1) the normal sounds of the heart, 
including their rhythm, their character and the seat of maximum in- 
tensity ; (2) modifications of the normal sounds as regards (a) loudness 
and (6) rhythm ; (3) the presence of abnormal sounds or murmurs. 

I. The Normal Sounds. The stethoscope is placed over the heart 
and the finger on the impulse or the radial pulse ; a sound will be noted 
at the time of the impulse or the systole, followed almost immediately 
by another sound and then a period of silence. The sounds that attend 
the systole are known as the systolic, or first sounds. The sounds that 
follow are known as the diastolic, or second sounds. The sounds and 

Fig. 162. 




Diagrammatic representation of the movements and sounds of the heart. (Afier Sharpey.) This 
diagram shows merely the general relations of the several events, and does not represent exact 
measurements. 

In a heart beating seventy-two times a minute, Foster estimates each entire cardiac cycle as 
occupying about 0.8 sec, of which 0.3 sec. represents the duration of the systole of the ventricle, 
0.4 sec. the diastole of both auricle and ventricle, or the " passive interval," and 0.1 sec the systole 
of the auricle. 

Only one '■ pause " is marked here— sometimes called the " long pause " ; some writers describe 
a "short pause" also— indicated in the diagram by the small space between the first and the 
second sound. 



silence mark the completion of a cardiac cycle as far as the ear is con- 
cerned. (Fig. 162.) A definite relationship in time exists in the car- 
diac cycle. Cause. Four sounds are created during a cycle, one at 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 621 

each, valve. The sounds created with the systole (systolic sounds) are 
due to contraction of the right ventricle and closure of the tricuspid 
valve ; and on the opposite side, of the left ventricle and the mitral 
valve. The rash of blood along the course of the vessels and the 
shock of the heart may contribute somewhat to the systolic sound. 
The sounds heard in the beginning of the diastole (diastolic sounds) 
are due to closure of the aortic and pulmonary valves. They are due 
to the tension produced on the valves as the respective arteries con- 
tract upon the columns of blood. The closures of the valves make 
up most, if not all, of the sounds. To review : two sounds occur with 
the systole, one from closure of the mitral, another from closure of 
the tricuspid valve ; two with the diastole from closure of the aortic 
and pulmonary valves, respectively. In health the sounds of the sys- 
tole blend because synchronous, giving the impression at a common 
point of one sound. Analysis of the sound in the respective valve 
areas will show that the systolic sound is made of two sounds. The 
sounds of the diastole may or may not blend. Often there is an appre- 
ciable difference between the two. 

Recognition of the Respective Sounds. To distinguish the sounds we 
study their rhythm or time, their character, their position of maximum 
intensity, and their direction of transmission. We distinguish the first 
from the second sounds by their rhythm and character, and then differ- 
entiate the sounds respectively of the systole and of the diastole by 
their point of maximum intensity. 

(a) The Rhythm or Time. The sounds that are heard at the time of 
the normal impulse or just before the radial pulse are the systolic or 
first sounds ; the sounds that follow the impulse are the second sounds. 
The sounds that follow the long silence are the systolic or first sounds ; 
those that precede the long silence are diastolic or second sounds. 

(b) Character of the Sounds. The systolic sounds are pro- 
longed, somewhat dull in character, low in pitch, and resemble the 
sound produced by the pronunciation of the syllable " ubbP The 
diastolic sounds are short, sharp, and quick, and resemble the sound 
produced by the pronunciation of the syllable " duppP The syllables 
ubb, dupp indicate the character of the sounds in health. Modifica- 
tions in the intensity of the sound are due to changes in the tension of 
the valve-curtains, and are dependent upon the force of muscular con- 
traction, which, if strong, renders the valves more tense. Experiment 
and the results of disease have aided in proving these points. 

(c) Position of Maximum Intensity. In general the first sounds 
are loudest at the lower part of the prsecordia, the second at the upper. 
But we especially distinguish the independent valve elements which 
make up the systolic and the diastolic sounds in the following manner. 
The sounds produced by the closure of the valves are created, as the 
topography of the heart shows, quite near to each other, but by con- 
duction of the sound they are transmitted away from the respective 
valves in particular directions, and heard loudest in definite areas on 
the chest. 

The Systolic or First Sounds. Two sounds are created. The 
valves which cause the sound are near to each other. Because of their 



622 



SPECIAL DIAGNOSIS. 



anatomical relations the sounds are conducted into different areas, by 
virtue of which they are differentiated. The Mitral Valve Sound. 
The sound produced by the closure of the mitral valve is created oppo- 
site the fourth interspace near the sternum. It is transmitted to the 
surface of the chest by the thickened left ventricle, and hence is heard 




Areas of cardiac murmurs (Gairdner for the areas ; and Luschka for the anatomy). The out- 
lines of organs, which are partially invisible in the dissection, are indicated by very fine dotted 
lines ; while the areas of propagation of valvular murmurs, as described in the text, have been 
roughly marked by additional much coarser and more visible dotted lines— the character of the 
dots being different in each of the four areas A capital letter marks each area — viz., A, the circle 
of mitral murmurs corresponding with the left apex; B, the irregular space indicating the ordi- 
nary limits of diffusion of aortic murmurs, corresponding mainly with the whole sternum, and 
extending into the neck along the course of the arteries ; C, the broad and somewhat diffused 
area occupied by tricuspid murmurs, and corresponding generally with the right ventricle ; D, the 
circumscribed circular area over which pulmonic murmurs are commonly heard loudest. 

Reference letters : r. au. = right auricle : a. o. = arch of aorta ; v. i. = the two innominate veins ; 
v. c. = vena cava descendens ; p. = pulmonary artery ; 1. au. = left auricle ; 1. v. = left ventricle ; 
r. v. = right ventricle. (Finlayson.) 



loudest where that is nearest the chest, namely, at the apex — the mitral 
area. The Tricuspid Valve Sound. The sound produced by the 
closure of the tricuspid valve is transmitted by the right ventricle, and 
is heard loudest over the lower portion of the sternum — the tricuspid 
area. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 623 

The Diastolic or Second Sounds. Two sounds are created. 
The valves at which they are produced are also in close proximity. 
To distinguish the two sounds it is necessary to auscnlt over areas into 
which they are transmitted. They may often be distinguished by 

Fig. 164. 




1. Mitral area. 



The valve areas. 
2. Tricuspid area. 3. Aortic area. 4. Pulmonary area. 



their slight difference in time, the aortic preceding the pulmonic by a 
fraction of a second. The Aortic Valve Sound. The sound produced 
by the closure of the aortic valve is heard loudest at the second costal 
cartilage on the right, because the aorta which conducts the sound is 
nearest the surface of the chest at this point — the aortic area. This 
cartilage is known as the aortic cartilage. The Pulmonary Valve 
Sound. The sound produced by the closure of the pulmonary valve is 
conducted to the left and heard loudest in the second interspace near 
the left edge of the sternum — the pulmonary area. 

(d) The Direction of Transmission. The first sounds are trans- 
mitted toward the axillae. They may be heard all over the cardiac 
area, but the position of maximum intensity is in the lower portion and 
toward the left. The second sounds are loudest at the base of the heart. 
They may be propagated beyond the prsecordia toward the neck, and 
be heard loudest in the vessels of the neck. 

Precise Location and Differentiation of Each Sound. 
This may be determined by listening with the bell of the stethoscope 
over each area. Then move the bell of the stethoscope gradually from 
one area into the other. As the sound of the original area lessens the 
sound of the approached area is observed. The change from one to 
the other is often very marked. 1. Mitral first or systolic sound, heard 
loudest at the apex, inward to the parasternal line, upward to the third 
interspace. 2. Tricuspid first or systolic sound, heard loudest at the 
lower part of the sternum and toward the left to the parasternal line as 
high as the third rib. 3. Aortic second or diastolic sound, heard loudest 
at the aortic cartilage, propagated into the vessels of the neck, and also 



624 SPECIAL DIAGNOSIS. 

heard at and outside of the apex-beat. It is louder than the pulmo- 
nary second sound in health. 4. Pulmonary second or diastolic sound, 
localized to the second interspace and the third rib. 

II. Modifications of the Sounds. The sounds, singly or com- 
bined, may be increased or diminished in intensity or accentuation. 
Thev may be altered in rhythm. 

Sounds Increased, a. Causes outside of the pericardium. 1. Any- 
thing which brings the heart closer to the ear of the observer. Thus, 
in patients with thin chest-walls, when the heart is pushed to the sur- 
face of the chest (mediastinal tumor) or the lung removed (pleural 
contraction). 2. Anything which conducts the sounds, as consolidated 
lung in the vicinity, or a pneumothorax, or pulmonary cavities, b. 
Affections of the pericardium, as pericardial adhesions, c. Conditions of 
the heart. 1. Hypertrophy. 2. Overaction, as in palpitation, fevers, 
anaemia, exophthalmic goitre. 

Sounds Weakened, a. Causes outside of the pericardium. 1. Gen- 
eral exhaustion. 2. Thick chest-walls, large mammary gland. 3. 
Emphysema of the lungs overlapping the heart, b. Affections of the 
pericardium, as fluid or air in the pericardial sac. c. Conditions of 
the heart. Atrophy ; myocarditis ; some cases of dilatation. 

In short, loudness of all the sounds occurs from (a) conditions out- 
side of the heart ; heart nearer chest-wall, consolidation of lungs, cavi- 
ties ; (6) conditions of the heart itself ; hypertrophy ; overaction. 
Weakness of the sound occurs from : (a) Conditions outside of the 
heart : thick chest-walls, emphysema, general exhaustion ; (6) affec- 
tions of the pericardium : effusions ; (c) affections of the heart : atro- 
phy ; dilatation ; myocarditis. 

Modifications of Individual Sounds. The above applies to all 
the sounds. Increase or diminution of the systolic or of the diastolic 
sounds, or of any one of the four sounds, may be present. 

Increase in Loudness of the Systolic Sound. Increased loud- 
ness of the first sound is noted when the muscle is hypertrophied, and 
the tension on the valves thereby increased. In hypertrophy of the 
left ventricle the increase is most marked. The sound is duller and 
has a prolongation which is very characteristic. In hypertrophy of 
the right ventricle the sound is dull and prolonged over the sternum, 
but not to the same degree as when the left is hypertrophied. 

Increase in Loudness of the Diastolic Sound. Either of the 
second or diastolic sounds may be increased in loudness or accentuated. 

Fig. 165. 

A 



Normal first Accentuated 

and second sounds. first sound. 



1. The Aortic Diastolic Sound. Anything which causes increased 
tension in the aortic circulation, and hence increased contractile force 
of the aorta, will increase the intensity or accentuation of the second 
sound. In hypertrophy of the heart the aortic sound is accentuated 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 625 

because there is corresponding increased contraction of the aorta, fol- 
lowing the forcible expulsion of the blood from the ventricle. Increase 
in arterial tension is also due to increased contraction of the aorta when 
there is peripheral resistance to the outflow of blood. It is associated 
with the following conditions which cause accentuation of the second 
sound : Atheroma of the aorta, or of the arteries in general ; aneurism 
of the aorta ; disease of the kidneys, and particularly in that form in 
which there are also general arterial changes — namely, chronic inter- 
stitial nephritis. It is true that the accentuation may be partly due 
to the hypertrophy of the heart which coexists. 

Accentuation of the aortic second sound occurs independently of per- 
manent change in the arteries. If for any reason there is spasm of the 
peripheral capillaries, as from a chill, from epilepsy, from nervousness 
due to hysteria, tension in the arteries is heightened, and hence the 
second sound accentuated. It is seen that accentuation of the second 
sound is, therefore, a marked index of the state of the vascular system 
in general ; it is not an evidence of disease of the heart alone. In 
certain fevers and in states of the blood in which the vasomotor nerves 
are irritated, causing peripheral contraction, as in scarlatina, accentu- 



Fig. 166. 



n 



Normal first and Accentuated 
second sounds. second sound. 

ation of the second sound is observed, often before the development of 
local inflammatory diseases due to the same cause, as nephritis in scar- 
latina. The occurrence of this complication may be suspected when 
accentuation of the aortic second sound is heard. 

2. The Pulmonary Diastolic Sound. This is due to the same phys- 
ical condition which causes accentuation of the aortic second sound. 
Anything which heightens the tension in the pulmonary artery will 
cause increased loudness. In health the pulmonary second is not so 
loud as the corresponding aortic sound. If, therefore, we find in the 
second or third left interspace the sound as loud as an aortic sound, or 
louder, it can be said that the pulmonary second sound is accentuated. 

It is due : 1. To any condition which causes congestion within the 
lungs, the right ventricle being at the same time of normal or increased 
strength. It is heard in the early stages of pneumonia, and, if the 
course of the disease continues favorable, may remain accentuated to 
the end. If, on the other hand, the circulation is embarrassed, and 
the right heart is failing, it will become fainter, and may be scarcely 
recognizable. Such change in the sound accompanies increase of respi- 
ratory distress, and indicates that the right heart is becoming ex- 
hausted. It is, therefore, an ominous sign in acute pulmonary disease. 
If the case is unfavorable, the signs of right-sided dilatation will sub- 
sequently occur. 2. It occurs in emphysema of the lungs. Notwith- 
standing the covering of the heart by the lung, the sound can be heard, 

40 



626 SPECIAL DIAGNOSIS. 

and may be the only one of the four sounds which can be distin- 
guished. 3. In valvular disease of the heart seated at the mitral orifice 
accentuation of the pulmonary second sound is heard, due to increased 
tension in the pulmonary artery. In mitral obstruction the blood is 
retained in the auricle and pulmonary veins, causing a resistance to 
the force of the right ventricle. Increased tension in the pulmonary 
artery is the result, with exaggerated strain upon the valves. In 
mitral regurgitation, with the systole the blood is thrown back into 
the auricle, and consequently meets with blood coming from the lungs. 
This in time increases the amount of blood and of blood-pressure in 
the pulmonary artery. A heightened tension results. Skoda pointed 
out the significance of this association. Sometimes in doubtful cases, 
either in the presence or absence of a murmur at the mitral orifice, the 
occurrence of this sign makes it more than probable that there is mitral 
valvulitis. 

Diminished Accentuation of Feebleness of the Sounds. 1. 
Feebleness of the Mitral Sound. Feebleness of the mitral sound ob- 
served at the apex of the heart may be an indication of weakness of 
the muscle from dilatation, atrophy, or myocarditis. It must be remem- 
bered, however, that weakness of the ventricle is not attended by en- 
feeblement of sound alone, but that when the right or left ventricle is 
Aveakened the duration of the sound is lessened. The loudness remains 
the same, or may be increased. Note, then, that a short systolic sound, 



Fig. 167. 



n 



EL 



Normal first and Diminished 
second sounds. first sound. 

loud, sharp, flapping, sometimes reverberating, heard at the apex, indi- 
cates dilatation or feebleness. The tension of the ventricles and valves 
creating the sound is increased by internal pressure. The systolic 
sounds become like the diastolic, and may be distinguished by the ear 
with difficulty ; but if the time is taken with the finger on the apex- 
beat or carotid artery, if the heart's action is slow the distinction can 
readily be made. 

Diminished Accentuation of the Aortic Sound. This is an indication 
of cardiac weakness, and is apt to ensue in the course of fevers when 
exhaustion takes place. It is a sign of myocarditis and of degenera- 
tion of the muscular walls of the heart. Under these circumstances 
the systole of the ventricle is also weakened. 

Feebleness of the aortic second sound, With hypertrophy and hence 
strong contraction of the ventricle, occurs when the aortic leaflets are 
swollen or enlarged and thickened. This condition of the valves is due 
to atheroma, and is in all probability associated with atheroma of adja- 
cent vessels, as the coronary arteries. It is, therefore, a sign of serious 
importance. 

Diminished Accentuation of the Pulmonary Sound. This is of impor- 
tance in the course of valvular disease of the heart, providing previous 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 627 

accentuation has been observed. If the marked loudness gives way to 
feebleness, there is strong probability that the right heart is under- 
going dilatation with regurgitation at the tricuspid orifice. While 
accentuation of the pulmonary second sound in valvular disease is of 
good omen, enfeeblement of the sound is of bad prognostic omen, indi- 
cating weakness of the right ventricle. 

Alterations in the Rhythm. Foetal rhythm of the heart : 
Embryocardia — a term first used by Huchard to designate a condition 
in which the pauses between the heart-sounds are of equal length. The 
first and second sounds are exactly alike, resembling the beat of the 
foetal heart. The sign is of importance in prognosis. In acute dis- 
ease and in fever it indicates enfeeblement of the heart and reduction 
of arterial tension. In the later stages of Graves' disease it is a fore- 
runner of death. It is distinguished from the rapid beat of the heart 
in tachycardia by the fact that in the latter condition the normal 
rhythm is preserved. 

Cantering Rhythm of the Heart The ear recognizes three sounds. 
The usual sounds may or may not be attended by murmur, and the 
interpolated sound may be dull, or short and sudden. It may occur at 
various periods in the cardiac cycle, either just before the systolic sound, 
just after the diastolic sound, or during the diastolic pause. The rhythm 
recalls the sound of a horse cantering. It was termed by Bouillaud 
the bruit de galop. When the interpolated sound resembles the first 
or second it is similar to reduplication of the sounds. It has been 
observed in hypertrophy of the heart, especially of the left ventricle ; 
dilatation of the heart ; in adherent pericardium with dilated hyper- 
trophy ; in myocarditis, in the course of fevers ; and in excessive 
anaemia. It is heard loudest over the right and left ventricles. 
Potain thinks it is due to tension communicated to the wall of the 
ventricle by the entrance of blood into its cavity, and is more marked 
when the wall is least extensible, as in hypertrophy on the one hand 
or exhaustion of the muscle ; in either of the two the walls vibrate 
more readily. The triple rhythm is of bad prognostic omen in chronic 
Bright's disease. 

Reduplication of the Sounds. Reduplication, or apparent 
doubling of the heart-sounds, occurs in various forms. In health the 
systolic sounds are created synchronously ; a fraction of a second, not 
appreciated by the ear, separates the diastolic sounds. In so-called 
reduplication one systolic sound may follow the other, or the aortic and 
pulmonary diastolic sounds may be created at distinct intervals. As 
has been stated, in galloping rhythm the idea of reduplication is some- 
times transmitted to the ear. Reduplication may take place in health 
under the influence of respiratory movements. The systolic sounds 
may be doubled at the end of expiration and the commencement of 
inspiration, while the diastolic sounds are doubled at the end of inspi- 
ration and the commencement of expiration. In mitral disease redu- 
plication, or want of synchronous closure of the two valves, is of fre- 
quent occurrence. The heart-sounds are doubled and heard over the 
base of the heart. Reduplication of the systolic sounds occurs in 
chronic Bright's disease. 



628 SPECIAL DIAGNOSIS. 

Reduplication, or Doubling of the Systolic Sounds, is heard over the 
apex or the right ventricle. Several explanations have been given 
for the cause of the reduplication. At first it was thought to be due 
to want of synchronism in the action of the ventricles — that one ven- 
tricle contracted before the other, due to the fact, of course, that the 
presence of blood stimulates one but not the other. By Hayden it 
was thought that reduplication of the first sound was due to the two 
major elements of the sound acting asynchronously, the muscular sound 



D 



Fig. 168. 

V 



a. b 

Normal first and Reduplicated 
second sounds. first sound. 

taking place before the sound produced by the tension of the valves. 
Dr. George Johnson took the view that the reduplication was due to 
the contraction of the auricle and ventricle ; that the sound produced 
by the former was heard on account of hypertrophy of the auricle, and 
heard first because of the natural order of precedence. Thus far the 
reasons for each view have not been fully established. 

Sansom believes that reduplication of the first sound is due to the 
shock communicated to the contents of the ventricle just before systole 
— that is, during the auricular-systolic period — in other words, it is 
due to the indirect effect of the auricular systole. The contraction of 
the auricle makes tense the auriculo-ventricular valve of the left side. 
If it occurs late in the diastole, or just before the systole, reduplication 
of the first sound is caused ; if early in the diastole, reduplication of 
the second sound is created. 

Reduplication of the Diastolic Sounds. While held by some authori- 
ties to occur in a large proportion of healthy individuals at the end of 
inspiration and the commencement of expiration, other observers, 
equally careful, think that it is extremely rare. It is of frequent 
occurrence in the patients of the Philadelphia Hospital. This is no 
doubt due to the fact that so many of the inmates are the subjects 
of all forms of lung disease, or disease of the vascular system, with 
muscular degeneration of the heart, that the equability of the pul- 
monic circulation is disturbed. There is no doubt that it can be 
modified or induced by inspiration. It is usually heard at the end of 
inspiration and commencement of expiration. Actual reduplication of 
the second sound occurs when the normal asynchronism of the closure 
of the aortic and pulmonary valves is exaggerated. It has been found 
that the valve of the pulmonary artery closes a fraction of a second 
after the aortic valve. The ear usually fails to appreciate the differ- 
ence unless there are differences of blood-pressure ; when doubled, and 
therefore appreciated, it is indicative of a difference in blood-pressure 
between the two sides of the circulation. Increased resistance in 
either will lead to increased tension, quickened recoil, and hence quick- 
ened closure of the valve. The conditions that are associated with the 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 629 

doubling of the second sound are (1) and most frequently, mitral sten- 
osis ; (2) obstruction of the circulation in the lung — tuberculosis, em- 
physema, and bronchopneumonia ; (3) dilatation of the right ventricle ; 
(4) myocarditis. The sound is heard at the second and third costal 
cartilages along the left edge of the sternum. It is frequently heard 
at the fourth and fifth cartilages on the left side. In cases of mitral 
stenosis it is heard near the apex. 

Fig. 169. 



Q_D D 



a. b 

Normal first and Reduplicated and 

second sounds. accentuated second sound. 
Illustrating diagrammatically modifications of the heart-sounds. (Gibson and Russell.) 

Simulated doubling, or false reduplication, is a sound produced at 
the mitral orifice. It is difficult to tell it from true doubling or redu- 
plication. It is most distinct at the base of the heart along the left 
edge of the sternum. Occasionally it is more distinct near the apex 
than elsewhere. It occurs with the conditions found in true doubling 
and in mitral obstruction. Cause. Sansom, Cheadle, and others dis- 
tinctly point out that this double second sound is of frequent occur- 
rence, and that it is heard most frequently at the apex. Sansom 
thinks that the cause for simulated doubling of the second sound is 
the same as for doubling of the first. There is, first, the normal second 
sound ; second, a tension of the mitral curtain producing the second 
simulated sound. This tension is due to the shock of the blood coming 
from the auricle to the ventricle. 

III. Abnormal Sounds or Murmurs. Abnormal sounds may be 
heard over the heart in addition to or replacing the normal sounds. 
These sounds are produced in the pericardium, in the heart, or in the 
bloodvessels. They are divided into friction-sounds and murmurs. 
They are recognized because they are a departure from the normal 
sounds or because they are superadded sounds. 

Abnormal Sounds in the Pericardium. They are known as 
friction-sounds and splashing or bubbling sounds. The former occur in 
the first stage of pericarditis, and are due to the rubbing together of 
the inflamed surfaces, either the congested, vascular pericardium, or 
the membrane bathed in exudation, or covered by lymph. The fric- 
tion-sound is recognized by (1) its character, (2) time, (3) position, (4) 
transmission, (5) movability, (6) modification by position of patient, 
pressure, course of disease, etc. 1. The pericardial friction is usually 
of a to-and-fro character, and can be recognized as distinct from the 
heart-sounds. It resembles the rubbing or scraping together of two 
roughened surfaces. 2. It is not necessarily synchronous with each 
sound. It is a to-and-fro sound, systolic and diastolic in time. It 
may, however, be only systolic or only diastolic. 3. It is heard over 
the body of the heart, usually in the third and fourth interspaces, or 
even over the right ventricle. 4. It is not transmitted away from the 



630 SPECIAL DIAGNOSIS. 

heart. Its location may shift from day to day in the precordial area. 
5. It may be modified by pressure or by respiratory movement, or be 
influenced by the position of the patient. It may disappear entirely 
in the upright posture. An impression of nearness to the ear is given 
by the sound observed in the first stage of pericarditis. It may be in- 
creased or lessened in loudness by a deep inspiration. It disappears 
during the period of effusion, to return after that is absorbed. 

Diagnosis. It must be distinguished from the pleural friction, which 
disappears if the patient is asked to hold his breath. The pericardial 
friction is of cardiac rhythm, the pleural friction of respiratory rhythm. 
It must also be distinguished from the so-called exocardial friction- 
sounds. The pleura adjacent to the pericardium may be inflamed. 
With each beat of the heart the rough surfaces of the pleura are agi- 
tated and generate a friction. It is seated along the edges of the right 
auricle or left ventricle. It is systolic in rhythm, but has the special 
characteristic that it is modified by respiration. It may be arrested if 
the patient holds his breath. It is increased by inspiration, or dimin- 
ished in expiration when the lungs recede from the heart in expiration. 
The pericardial friction must be distinguished from the crepitations 
and rales of cardiac rhythm produced by the impact of the heart 
against the lung. They disappear when the breath is held. The dis- 
tinctions between pericardial frictions and cardiac murmurs will be 
considered later. 

Splashing sounds are heard when there are air and fluid in the peri- 
cardium. They may be bubbling or gurgling or resemble the sound 
of a water-wheel. They continue when the breath is held. 

Abnormal Sounds in the Heart and Vessels. Murmurs. 
If the student listens with the stethoscope over a large superficial 
vessel, and does not employ pressure, he will not detect any sound. 
If, however, pressure is employed, a sound or murmur is produced. 
The passage of the blood through the vessel produces no sound because 
the vessel or tube is of equal calibre. The pressure of the stethoscope 
alters the calibre and compels the fluid to pass through a narrow orifice 
into a wider space. In this manner a fluid vein is produced. The 
vibration of the molecules of the agitated fluid vein produces a sound 
or murmur. The loudness of the sound depends upon the swiftness 
of the flow. The sound in this instance is carried in the direction of 
the blood-current, hence the murmur is known as an onward murmur. 

The reverse may take place. The fluid may flow backward from a 
wider into a narrower space without the production of sound ; if, how- 
ever, the fluid breaks on bevelled edges, as the leaflets of heart-valves 
projecting into the current, the fluid is again thrown into vibration and 
produces noise. If there is considerable constriction by the bevelled 
edge, the sound is carried farthest against the natural flow of the fluid 
— hence the term backward murmur. Some authors hold that mur- 
murs are also due to lateral vibrations of the walls of the heart or of 
the vessels. Some murmurs may resemble tones, and are called musi- 
cal murmurs. Such murmurs are due either to the vibrations of the 
solids set up by the vibrating fluid vein, or to the vibrations of the 
fluid vein alone. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 631 

Murmurs are divided into two classes, in accordance with their seat 
of development. Murmurs originating in the heart are known as car- 
diac murmurs. Murmurs originating in the bloodvessels are vascular 
murmurs. (See The Arteries.) Cardiac and vascular murmurs are 
divided into (1) organic murmurs, if due to physical changes of the 
heart or vessels ; (2) inorganic, functional, or hcemic, if due to changes 
in the quality of the blood. (See Functional Murmurs.) Cardiac 
murmurs are always generated at the orifices from disease or from 
incompetency of the valves, or from patulous non-valve opening. The 
orifices are valvular and non-valvular. 

Murmurs at Valvular Orifices. The valvular orifices and 
their anatomical relations have been described. Murmurs are produced 
at these orifices when they are open or when normally they should be 
closed. If the murmur is produced when the orifice is open it is 
because there is narrowing of the orifice or dilatation of the cavity 
(relative narrowing). The murmur, then, is always produced with the 
natural current of blood, and hence is known as an onward or obstructive 
murmur. It always or nearly always implies organic disease at the 
valve-orifice, hsemic murmurs excluded. If the murmur is produced 
when the orifice should be closed, and hence when the valve leaks, it is 
because the valves are diseased and cannot shut the orifice, or because 
they are too small — incompetent — to shut it. Such murmurs are pro- 
duced against the natural current of blood, and are known as backward 
or regurgitant murmurs. 

Murmurs at Non- valvular Orifices. The orifices of the vena 
cavse and of the pulmonary veins, and of the perforations of the septa 
in congenital heart disease, are non-valvular. They are at times the 
seat of murmurs — as in open foramen ovale or perforated ventricular 
septum. 

Diagnosis of Murmurs. The student has learned that an abnor- 
mal sound or a murmur is present. It is necessary then to determine, 
first, at which orifice the murmur is produced (the seat of the murmur) 
and, second, the kind of murmur — obstructive or regurgitant. Mur- 
murs are therefore studied as heart-sounds are studied, as to their 
position of maximum intensity, their time, and the direction of their 
transmission. The position of the murmur indicates which valve- 
orifice is affected, the time and the direction of transmission, and the 
kind of murmur. 

The Position of Maximum Intensity of the Murmur. The 
Orifice Affected. We are enabled accurately to determine the orifice 
at which the murmur is generated by noting the position of maximum 
intensity of the murmur. This corresponds to the area at which the 
normal sound of the respective valve is heard loudest. It may be re- 
membered that the cardiac orifices are closely situated, and that, there- 
fore, the murmurs must be generated within a small area, so small that 
it would be impossible to ascertain at which valve-orifice the murmur 
is created, were it not for the fact that under the laws of conduction of 
sound the murmurs are conducted away from their point of origin to 
certain definite stations, where in health the respective valve-sound is 
also heard loudest. 



632 



SPECIAL DIAGNOSIS. 



1. Murmurs at the Apex — the Mitral Area. A murmur heard 
loudest, or with the greatest intensity, at the apex is known as a mitral 
murmur. It is created at the mitral orifice, but is conducted to the 
apex by the left ventricle, which is nearest the chest- wall at this point. 
(See 1,'Fig. 164.) 

2. Murmurs at the Xiphoid Cartilage — the Tricuspid Area. The 
murmur is heard loudest at the xiphoid cartilage or the head of the 
fourth or fifth rib. It is created at the tricuspid orifice, and is heard 
most distinctly over the lower portion of the sternum, and along the 
left edge, because the right ventricle is in apposition with the chest- 
wall at this spot. (See 2, Fig. 164.) 

3. Murmurs at the Second Costal Cartilage or Second Interspace on 
the Right — the Aortic Area. When a murmur is heard with great- 
est intensity at this point it is usually generated at the aortic orifice, 
and is conducted to this region by the aorta, which comes nearest to 
the surface of the chest at this point. (See 3, Fig. 164.) 

4. Murmurs in the Second Left Interspace — the Pulmonic Area. A 
murmur heard loudest at the second interspace along the left edge of 
the sternum is generated at the pulmonary orifice ; it is heard loudest 
in this area because the pulmonary artery is nearest the chest at this 
point. (See 4, Fig. 164.) 

The Rhythm or Time of the Murmur. The Kind of Murmur. 
Having determined the point of maximum intensity of the murmur, 
hence the valve at which it has its origin, we next wish to determine 
the kind of murmur. A murmur which is produced at orifices when 
they should be closed is known as the murmur of regurgitation, as the 
valve permits the blood to flow backward. A murmur that occurs 



Fig. 170. 




Maximum inteusity of murmur of mitra 1 regurgitation ; systolic ; transmitted to trie left. 



when the blood should in health be passing through an orifice is known 
as a murmur of obstruction, as the flow of blood is obstructed. We 
have to determine whether the murmur at an orifice is due to regurgi- 
tation or to obstruction. This is ascertained by the time of the murmur. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 633 

The time of the murmur is determined by the heart-sounds, by the 
impulse, and by the pulse. 

Murmurs with the Systole. 

1. In the Mitral Area. In health, during this time, the auriculo- 
ventricular valve is closed. The murmur indicates there is such dis- 
ease as to permit of a backward flow of blood, or of regurgitation, into 
the auricle. It is the murmur of mitral regurgitation. It may be due 
to disease of the valves or to incompetency. (See Fig. 170.) 

Fig. 171. 




Maximum intensity of murmur of tricuspid regurgitation ; systolic. 

2. In the Tricuspid Area. As on the left side, the murmur in this 
area is due to valvular disease or valvular incompetency, which per- 
mits of regurgitation, tricuspid regurgitation. (See Fig. 171.) 

Fig. 172. 




Position of maximum intensity and directions of transmission of murmur of aortic obstruction. 



3. In the Aortic Area. During this time the blood is flowing from 
the ventricle into the aorta. If there is disease which causes obstruc- 
tion at the orifice the murmur of aortic obstruction is produced. The 



634 



SPECIAL DIAGNOSIS. 



murmur may be due to anaemia ; to disease of the aorta, or to its mal- 
position. (See Fig. 172.) 

4. In the Pulmonary Area. The pulmonary orifice is affected in 
the same way as the aortic orifice under the same circumstances. The 
murmur is due to pulmonary obstruction. It is exceedingly rare. It 
is more frequently hsemic. (See Fig. 175.) 

Murmurs with the Diastole. 

1. In the Mitral Area. The blood is flowing from the left auricle 
to the left ventricle. Disease of the valves obstructs the flow. The 
murmur occurs in the beginning, in the middle, or at the end of the 
long silence. Mid-diastolic and late diastolic, or because it occurs 
before the systole, presystolic, are the terms applied to this murmur. 
It is the murmur of mitral obstruction. (See Fig. 173.) 

Fig. 173. 




Maximum intensity of murmur of mitral obstruction ; presystolic, localized or transmitted as 

area shows. 
1. Normal impulse. O. Area of reduplication of second sound. 



2. In the Tricuspid Area. It occurs for the same reason and at the 
same time as the diastolic murmurs generated at the mitral orifice. 
It is rare, although more common than usually supposed, to find tri- 
cuspid obstruction. 

3. In the Aortic Area. The aortic valve closes in the diastole. A 
murmur indicates it is so diseased that it cannot prevent blood flowing 
backward or regurgitating into the ventricle. It is the murmur of 
aortic regurgitation. A murmur of the same time and in the same 
situation may be due to dilatation or aneurism of the aorta. (See Fig. 
174.) 

4. In the Pulmonary Area. A diastolic murmur in this area is due 
to regurgitation at the pulmonary orifice. (See Fig. 175.) 

Murmurs are divided as to time into systolic and diastolic murmurs. 
The above shows that we may have practically only three systolic and 
two diastolic murmurs. The systolic murmurs are aortic obstruction 
and mitral and tricuspid regurgitation. The diastolic murmurs are 
aortic regurgitation and mitral obstruction. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 635 

The Direction of Transmission. It depends upon the situation 
of the murmur and the time at which it is produced. Some murmurs 
are not transmitted. The transmission is usually in the direction of 
the currents which produce them. 



Fig. 174. 




Positions of maximum intensity and directions of transmission of murmur of aortic regurgitation. 

Murmurs in the Mitral Area. To the axilla. A murmur which is 
produced at the apex with the systole, caused by regurgitation at the 
mitral orifice, is transmitted into the axilla, and may be heard at the 
angle of the scapula. The murmur which is produced in the same 
area before the systole — obstruction — is usually not transmitted. It is 
heard at the apex, or a little inside of the apex, or may rarely have its 
point of maximum intensity in the third interspace. Sometimes it is 
transmitted to the axilla and to the angle of the scapula. (See Figs. 
170 and 173.) 

Murmurs in the Tricuspid Area. The murmur of tricuspid regurgi- 
tation is not transmitted. It is heard over a relatively large area, de- 
pending upon the intensity of the sounds. 

Murmurs in the Aortic Area. Upward and Along the Vessels. The 
murmur, systolic in time, heard at the second costal cartilage on the 
right, due to aortic obstruction, is transmitted in the direction of the 
blood-current. The sound is conducted by the vessels and by the 
fluid ; it is, therefore, heard along the course of the aorta and in the 
carotid arteries. Downward to the Apex. The murmur of aortic re- 
gurgitation, heard in the same area, is transmitted downward along the 
course of the sternum. It may be transmitted to the apex, or may 
be heard along the sternum only. The left ventricle conducts this 
murmur. (See Figs. 172 and 174.) 

Character of the Murmurs. Murmurs are further distinguished 
by their character and the degree of loudness. By the character of the 
murmurs we are aided (1) in distinguishing them from heart-sounds ; 

(2) in estimating the nature of the lesion that produces the murmur ; 

(3) in judging, in the case of murmur of mitral obstruction, of the 
presence or absence of that disease. 



636 



SPECIAL DIAGNOSIS. 



Distinction from Normal Sounds. Normal sounds are sounds 
of tension ; murmurs are sounds of rhythmical vibration. The normal 
sounds of the heart have been described by the syllable " ubb" " dupp," 
" od," and abnormal sounds of endocardial origin by " uf" " uv," 



Fig. 175. 




Maximum intensity of pulmonary systolic murmur. 
O . Area of murmur of anaemia. 



ush," or by full vowel sounds as " oo, 



» it „, 99 it 



ah," and "aw," 



by musical tones, or by interrupted tones, or by general sounds, as 

a urr 77 or a orr » 

The Nature of the Lesion. The murmurs may be rough or rasping, 
musical or whistling in character. They may be high or low in pitch. 
Murmurs that are rough and high in pitch are usually due to disease 
of the valves, causing thickening or stiffening of the leaflets, or to the 
projection of an atheromatous plate into the lumen of the orifice. Such 
conditions occur in chronic endarteritis and chronic endocarditis or 
valvulitis. On the other hand, murmurs that are soft and low in pitch 
are usually due to a physical condition which causes swelling of the 
valve or occlusion by soft exudations ; they are heard in endocarditis 
of rheumatic origin, or the malignant form of endocarditis. The only 
murmur which has special characteristics is the murmur of mitral 
obstruction. It is a prolonged murmur of a churning or grinding char- 
acter, sometimes rippling, and as if fluid were being forced through a 
narrow channel. It is usually presystolic, but may occur in the middle 
of the diastole. 

Loudness. The loudness of the murmur is not of special signifi- 
cance, although, in general, it may be said that it indicates good com- 
pensation, and that the heart muscle is sufficiently strong to meet the 
demands of the circulation. Murmurs are louder in the recumbent 
than in the erect posture in some instances, especially mitral and tricus- 
pid murmurs. Murmurs are often more distinct after exertion. Loud 
murmurs may become weak, and this change in character of the sound 
is of serious omen. They may disappear in the course of fevers and 
in the dying state. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 637 

Disappearance of Murmur. The student will often find that 
after a patient has been under treatment for a short time the murmurs 
disappear. This is probably due to the fact that there is complete 
compensation. In the terminal stages of cardiac disease they disap- 
pear because of weakness of the heart muscle. Rarely they disappear 
because the roughened valve causing them has been repaired. (See 
" Disappearance of Murmurs/ 7 by the author. British Medical Journal, 
1897.) In other cases it may be necessary to bring out a faint mur- 
mur or increase its intensity by having the patient move about ; this 
renders it more distinct by inducing more rapid action of the heart. 

The Significance of Murmurs. Murmurs heard at the various 
orifices indicate either (1) disease of the valves ; (2) incompetency of 
the valves ; (3) disease of the blood ; or (4) disease of the vessels in 
intimate relation with the heart. The systolic murmur at the second 
costal cartilage on the right may be heard when there is disease at the 
aortic orifice, causing obstruction ; in atheroma of the aorta ; in cases 
of aneurism just above the valves ; in anaemia, and chlorosis, and in 
some vasomotor neuroses, as Graves' disease. Before concluding that 
the murmur is due to disease of the valves we must be able to exclude 
the other conditions. Atheroma of the aorta, is most difficult to distin- 
guish from obstruction, because the character of the murmur is the 
same and the associated conditions are similar. In both there may be 
a previous history of gout, rheumatism, syphilis, or alcoholism. The 
latter are associated with atheroma in other arteries of the body, and 
with degenerative changes that accompany atheroma. In young sub- 
jects, in whom there has been a direct history of rheumatism, or when 
the process has followed septicaemia, the probabilities are, in nearly 
all the cases, that the murmur is due to aortic obstruction. To dis- 
tinguish the murmur of anaemia, chlorosis, or Graves' diseases is often 
difficult. The associate symptoms in each case are different, however, 
and with the changes in the blood indicate the nature of the murmur. 

In other valve areas the chief task is to decide whether the murmur 
is orgamc, due to valvulitis, or whether it is functional, due to incompe- 
tency or to anaemia. 

Murmurs due to Incompetency. The valves are sometimes 
unable to close properly. The cavity of the ventricles may increase 
in size, so that the valves do not coapfcate to close the widened orifice. 
The tricuspid and mitral valve leaflets often become thus incompetent. 
Mitral and tricuspid regurgitation ensue. The murmurs are soft and 
low in pitch and not widely transmitted ; the heart is dilated. 

Murmurs of Anemia. The murmurs of anaemia have some char- 
acteristics which aid in distinguishing them from true organic mur- 
murs. The most important of these are : (1) The situation of the mur- 
mur ; (2) its character ; (3) the direction in Avhich it is transmitted ; (4) 
the time ; (5) the associate signs ; (6) the secondary heart-muscle changes. 
1. The murmurs of anaemia may be heard at any orifice, but are usually 
heard at the second costal cartilage, or the third interspace, on the left 
side. They are generated at the pulmonary orifice, or in the cone of 
the right ventricle. The murmur at the pulmonary orifice may be 
heard as high as the second interspace, but otherwise is not transmitted. 



638 



SPECIAL DIAGNOSIS. 



Murmurs of anaemia are also heard at the apex, at the aortic cartilage? 
and over the tricuspid area. They are comparatively infrequent in 
these situations, but partake of the same nature as the murmur heard 
at the pulmonary orifice. 2. They are soft in character and low in 
pitch. They are louder in the recumbent than in the upright posi- 
tion. Their loudness is increased by violent cardiac action. They 
are loudest just at the end of expiration or beginning of inspiration. 
3. They are not transmitted away from the heart. 4. They are systolic 
in time. 5. They are associated with murmurs in other parts of the 
vascular system, as the murmur in the jugular veins. Its characteris- 
tics and mode of recognition will be described elsewhere. 6. Mural 
changes, as general dilatation, fatty degeneration, or hypertrophy may 
be present ; but single chambers do not undergo change. The murmur 
of anaemia may usually be considered to be temporary. 



Fig. 176. 




Maximum intensity of murmurs of anaemia, systolic. iSansom.) 

1 Pulmonary artery, 59 per cent. 2. Apex, 7 per cent. 3. Right v. and conus, 11 per cent. 

4. Aortic area, 11 per cent. 1 and 2. Pulmonary and apex coexisting, 9 per cent. 

Functional Murmurs not Anemic. Drummond divides func- 
tional murmurs into three classes : cardio-haemic or anaemic ; cardio- 
muscular or neuro-typtic, and cardio-respiratory. The first has been 
considered above. The eardio-muscular murmur attends excited action 
of the heart. It is heard loudest at the fourth left interspace close to 
the sternum ; loudest in the upright posture ; loudest at the end of 
expiration. It disappears at the end of inspiration, or when the patient 
lies on the side. Of course, it is increased by exertion and excitement. 
It is rough or whizzing in character. The cardio-respiratory murmur 
is fairly common. It is most marked in inspiration, but may be heard 
in both acts. It is systolic in time, and is heard loudest at the apex, 
but I have often heard it along the left border of the heart, as high as 
the second rib and in the axilla, and at the angle of the scapula. It is 
short and whiffing, and the sound gives one the impression that the 
heart is striking the lung. 

Influence of Pressure. Pressure exerted, Sewall says, while using 
the flexible stethoscope over the second costal interspace annuls in part, 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 639 

or wholly, the second sound of the heart ; but if the ascending aorta 
be dilated or the site of an aneurism, the second sound persists strongly 
notwithstanding firm pressure. 
Further, firm pressure removes — 

(A) 1. Hsemic murmurs over the base of the heart (save Jenner's 

pulmonary murmurs). 

2. An aortic obstructive murmur of the apex. 

3. When mitral and aortic regurgitant murmurs coexist, the 

aortic murmur is diminished in the greater degree. 

4. Aortic regurgitant murmurs over the second right intercostal 

space. 

While it does not markedly affect — 

(B) 1. Mitral regurgitant murmurs heard over the apex ; or 

2. Mitral obstructive murmurs over the same spot. 

3. Tricuspid regurgitant murmurs over the area of greatest in- 

tensity. 

4. Aortic regurgitant murmurs over the apex (see (A), No. 3). 

Secondary Effect of Valve-lesions on the Heart and Pulse. 

The secondary effect of valve-lesions on the heart and pulse aid in the 
diagnosis. While we are enabled by the time of the murmur, the posi- 
tion, and the direction of transmission to affirm the nature of the dis- 
ease at the respective valve-orifices, other physical signs further aid 
us in determining more precisely the lesion and its seat. They are 
derived from the heart and the pulse. They depend upon the second- 
ary effect of the lesion upon the heart and upon the circulation. In 
aortic obstruction, on account of obstruction to the flow of blood, the 
left ventricle hypertrophies ; moreover, the blood stream is lessened in 
volume, and hence the pulse is small and of high tension. The physi- 
cal signs of hypertrophy and small pulse are corroborative evidence of 
this lesion at the left orifice. In aortic regurgitation the blood flows 
back into the ventricle. On this account, therefore, some dilatation 
takes place, a dilatation which, if compensation is perfect, is overcome 
by hypertrophy. The signs, however, of enlarged left heart are pres- 
ent, as shown by inspection, palpation, and percussion. But the pulse 
of aortic regurgitation is of the greatest diagnostic significance. With 
the finger on the radial, the impression is at once received of recedence 
of the pulse- wave as soon as it strikes the finger. This is more marked 
if the hand is elevated. It is the water-hammer, or Corrigan's, pulse. 
In mitral regurgitation the left auricle does not change, but the stress 
is thrown upon the right side of the heart, and we have the signs of 
right-sided hypertrophy and dilatation ; but more marked than this is 
the evidence of high tension of the pulmonary artery, shown by accen- 
tuation of the second sound. (See p. 625.) In mitral regurgitation, 
the blood flows back into the auricle, and when the right heart weak- 
ens engorges the venous system. The arterial system is in consequence 
devoid of blood, and hence the arteries are empty. The pulse is small 
and feeble. The depleted coronary arteries do not nourish the ven- 
tricles, hence dilatation or failure in nutrition soon ensues, and the 



640 SPECIAL DIAGNOSIS. 

heart is further weakened. In addition to being small and feeble, the 
pulse, on account of inefficient and hurried contractions of the ventricle, 
is irregular and intermittent. 

In mitral obstruction, in addition to the characteristic murmur, the 
thrill is of great significance. Moreover, the left auricle hypertrophies, 
and shortly afterward the right heart. It is accompanied by an ac- 
centuated pulmonary second sound, and frequently by doubling of that 
sound. The pulse is small and feeble. 

Multiple Cardiac Murmurs. More than one murmur may be 
heard over the heart. The number depends upon the number of 
valves that are the seat of disease and the lesions at the orifices. We 
may have valvulitis of the aortic, mitral, and tricuspid valves conjoined. 
More commonly one valve is diseased, giving rise to a murmur, while 
another valve is incompetent, on account of dilatation, and a murmur 
thus generated at its orifice It is common to see aortic obstruction 
from valvulitis and mitral regurgitation from incompetency ; mitral 
obstruction or regurgitation from valvulitis, and tricuspid regurgita- 
tion from incompetency. I have seen double aortic disease (combined 
obstruction and regurgitation), double mitral disease, and tricuspid 
regurgitation. The diagnosis of the various murmurs will be dis- 
cussed in the chapter on Valvulitis. 

The Arteries. The stethoscope should always be used in examining 
the arteries. The double stethoscope is preferable, as strong pressure 
must be avoided upon the vessels. When the single stethoscope is used 
some diagnostic value attaches to the character of the shock that is trans- 
mitted to the head. The arteries open to auscultation are the carotids 
when the neck is slightly extended ; the subclavian ; the innominate 
above the stern o-clavicular articulation ; the brachial artery in the 
bend of the elbow, with the arm slightly extended ; and the crural 
artery just below Poupart's ligament. The normal systolic and dias- 
tolic heart-sounds are often heard in the carotid and subclavian arte- 
ries. The systolic sounds may be heard over the abdominal aorta, 
due to tension of the vessels. The diastolic sound is rarely heard in 
this situation. In the other vessels no sounds are heard. 

Induced or pressure-murmur. By pressure with the stethoscope over 
one of the vessels its calibre is modified and a murmur created. This 
murmur corresponds in time with the pulse, hence it is systolic, and 
increases or diminishes in intensity, depending upon the amount of 
pressure placed upon it. Just here may be mentioned the systolic 
humming which is heard in children between the third month and the 
sixth year over the fontanelles and sometimes over the rest of the 
head. (See The Head.) 

Abnormal Sounds. Abnormal sounds or murmurs are due to 
alterations of the blood, disease outside of the vessels causing pressure, 
and disease of the vessels. Murmurs from disease of the vessels, as 
the aorta, are discussed under the head of arterio-sclerosis or aneurism. 

Conduction Murmurs. Murmurs may be propagated into the 
arteries. A systolic murmur created at the aortic orifice may be heard 
in the vessels of the neck and along the aorta. On the other hand, 
in aortic regurgitation, the diastolic sound normal in the carotid and 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 641 

subclavian disappears, and the diastolic murmur is not heard. Double 
Sounds of the Vessels. Double sounds are sometimes heard in the 
crural artery under the following circumstances : (1) In aortic insuffi- 
ciency ; (2) in mitral stenosis ; (3) in lead-poisoning ; (4) in pregnancy. 
Duroziez's double murmur, heard when greater pressure is used by the 
stethoscope, occurs in aortic regurgitation when there is good compen- 
sation. Many authorities refer to this as a valuable diagnostic sign 
in this affection. The double sound in all instances occurs with large 
and quick pulse. It is probably caused by sudden collapse of the 
artery, and the reflux blood-current which is possibly an aortic regur- 
gitation. 

Murmurs due to Alterations of the Blood. They are gen- 
erated in anaemia and chlorosis. They are called functional murmurs, 
to distinguish them from murmurs due to disease of the vessels. They 
are systolic in time. They are soft and low in pitch, often of a musical 
character. The degree of loudness may vary with the position of the 
patient. They are increased by excitement. The intensity of the mur- 
mur increases in the course of fevers. 

Murmurs in Relaxed Vessels. Murmurs in the vessels, appar- 
ently of functional origin, are sometimes heard. The vessels are 
dilated from actual disease. The increased calibre favors the develop- 
ment of a murmur by the creation of a fluid vein. Dilatation of the 
innominate artery sometimes takes place, giving rise to a murmur, which 
in loudness and character simulates the murmur of aneurism. A 
functional murmur is sometimes heard in the vessels, independently of 
disease, in cases of aortic regurgitation. The murmur is systolic in 
time. 

Pressure-murmurs. Pressure of the stethoscope, or that caused 
by diseases outside of the bloodvessels. When heard over the subclavian 
artery, the pressure-murmur may be due to adhesions or consolidation 
at the apex of the lung. It is more frequently heard at the left, and 
may only be present during full expansion of the lung. It is due to 
temporary pulling or bending of the artery during deep breathing. 
When it occurs on both sides it is not of much significance. Murmurs 
in the axillary artery, or in any arteries surrounded by enlarged lym- 
phatic glands, are created by their pressure. Murmurs in the thyroid 
gland have been referred to. (See Goitre.) 

Murmurs due to Disease of the Arteries. In the aorta the 
murmurs are due to aneurism or atheroma, or both., They may be 
systolic or diastolic. In the smaller vessels both conditions may be 
present, although atheroma is the usual one. The murmur is systolic 
in time, rough in character, strong or weak. It is associated with 
other signs of atheroma. 

The VeinS. In health no sounds are heard. Two conditions 
contribute to the creation of a murmur in the veins : (1) Change in the 
character of the blood ; (2) dilatation with the occurrence of positive 
venous pulse. 

The Venous Hum. In anaemia and chlorosis, and sometimes in 
healthy patients, a hum or murmur, or buzzing sound is heard over 
the jugular veins. It is louder on the right side than on the left. It is 

41 



642 SPECIAL DIAGNOSIS. 

soft and low in pitch, and may be musical ; it has been described as 
humming or whizzing. It is continuous. For its detection a double 
stethoscope should be used, as pressure increases it, and the patient 
should not turn the head to one side, as it is increased when this posi- 
tion is taken. The murmur is modified by the respiration and by the 
cardiac action. It is louder in deep inspiration when the blood is 
going more rapidly to the thorax. It is also louder in the upright 
position. It is frequently louder during the diastole. The increased 
loudness at these periods occurs because, from the sucking action 
during inspiration and during the diastole, the blood is more rapidly 
drawn toward the heart. The murmur is caused by the flow of blood 
from the narrow jugular into its wider bulb, producing a fluid vein. 
Later authorities believe it to be due to lateral vibration of the walls 
of the veins. Similar murmurs are heard in other veins, as in those 
of the extremities when the anaemia is profound. They are stronger 
during the diastole of the heart. The venous hum is sometimes heard 
at the lower border of the liver, to the right of the median line, in 
cirrhosis of the liver. It is created in the enlarged collateral veins. 
It may be modified by pressure of the stethoscope. It may be heard 
in this situation in emaciated and cachectic subjects not the subject of 
cirrhosis. The venous hum may be heard in the innominate ' veins 
(first and second interspaces and right costo-clavicular articulation), in 
the subclavian and axillary veins. 

Pericarditis. 

Inflammation of the Pericardium. The inflammation may be 
acute or chronic. It is also divided according to the nature of the in- 
flammation into simple fibrinous inflammation and inflammation with 
effusion. The effusion may be serous, bloody, or purulent, depending 
upon the nature of the inflammation. Pericarditis, either acute or 
chronic, is also divided into primary or secondary pericarditis. The 
primary form is of extremely rare occurrence. Indeed, it may well 
be doubted whether, in common with the inflammations of serous 
membranes in general, pericarditis is ever primary, or so-called idio- 
pathic, in origin. 

Causes. 1. Extension from Neighboring Structures. Extension of 
the inflammation from infected tissues in the vicinity is a common 
cause of pericarditis. It may follow a pleurisy and partake of the 
nature of the primary pleural inflammation. It often attends em- 
pyema, either from extension of the infection to the pericardium or 
from rupture into the pericardial sac. It may follow all forms of in- 
flammation of the mediastinum. Disease of the ribs adjacent to the 
pericardium may set up pericarditis, acute and chronic. It attends 
on the course of aortic aneurism, at times, but more frequently in- 
fectious endocarditis and myocarditis. Inflammations below the 
diaphragm frequently give rise to pericarditis. Peritonitis, when 
general or local ; sub-diaphragmatic abscess ; suppurative gastritis, 
with perforation of the stomach ; abscess of the liver ; suppurating 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 643 

hydatid, and other forms of suppuration below the diaphragm, belong 
to the latter. 

2. General Infections. The general diseases causing inflammation of 
the pericardium are those which affect serous membranes. They are : 
Infectious diseases, particularly scarlet fever, measles, erysipelas, and 
tvphoid fever. All forms of septicaemia may be attended by inflamma- 
tion of the pericardium. Tuberculosis is a frequent cause of pericar- 
ditis. Inflammation of this membrane frequently arises in the course 
of rheumatism. It may occur in the course of the disease, or attend 
some of the affections which are themselves manifestations of rheuma- 
tism, such as acute tonsillitis. In the course of certain dyscrasise the 
pericardium is frequently the seat of inflammation because more vulner- 
able. This is particularly the case in scurvy. It occurs also in Bright' s 
disease, and may be the first manifestation to the patient of this disease, 
particularly in the chronic form of nephritis. It occurs in the course 
of gout. 

The various forms of pericarditis may occur at any age, although 
that which attends scarlatina and rheumatism occurs in early life, while 
late in life it is an attendant upon chronic Bright' s disease and gout. 

Acute Fibrinous or Plastic Pericarditis. 

This is probably the most common form that is seen. It is the 
variety that attends Bright's disease, rheumatism, and tuberculosis. 
It may be wanting entirely in symptoms. An examination of the 
heart in the routine of duty may reveal its presence by physical signs. 
In the course of one of the primary causal diseases, if the tempera- 
ture rises a little higher than it should, or convalescence is delayed, 
pericarditis should be suspected. Again, if the pulse is more rapid 
and quicker than customary at the period of disease the examina- 
tion is made, or out of proportion to the temperature, the disease 
should be suspected. There may be altered rhythm or tumultuous 
action. In other instances the patient may complain of pain in the 
region of the heart. It is usually localized in the fourth or fifth inter- 
space. It is not very severe and not influenced by pressure. Some- 
times the pain is complained of at the xiphoid cartilage. In rare 
instances it may resemble angina. The pain and the occurrence of 
fever further call attention to the heart. 

Physical Signs. Inspection. Nothing unusual is observed, although 
the heart may be seen to beat more violently against the chest- wall. 
The impulse is diffused. 

Palpation. A friction-fremitus may be detected, due to the rub- 
bing together of the roughened pericardial surfaces. It is not always 
present. It may be felt when the whole hand is laid over the prsecor- 
dia, or by palpation with the tips of the fingers. It is most marked 
over the right ventricle, particularly in the fourth interspace, and is 
increased when the patient leans forward. 

Auscultation. A friction-sound is usually present. It may be present 
while the fremitus is absent ; but, on the other hand, if the fremitus 



644 * SPECIAL DIAGNOSIS. 

is present, we can always hear the friction. It is heard over the -region 
where the fremitus is felt. 

Point of Maximum Intensity. It may be heard along the course of 
the sternum It is usually heard in the third or fourth interspace, 
but may be heard as high as the second, adjacent to the sternum in 
either interspace. Sometimes it is heard at the second costal cartilage 
on the right, rarely at the apex. The point of maximum intensity 
may vary with the position of the patient. 

Time. It is both systolic and diastolic. In some cases it may be 
only systolic in time, or it may be of a galloping nature, representing 
three sounds during the cardiac cycle. Again, the to-and-fro sound is 
not synchronous with the systolic and diastolic sound, although it 
occurs but oncq in the cardiac cycle. It may begin after systole, and 
be completed before the end of the diastole. The impression that it 
is a superadded sound is most positive. 

Direction of Transmission. It is localized, and not transmitted. 

Character. It is a to-and-fro rubbing, scratching, or grating sound ; 
it gives the impression of being near the ear. It may be modified by 
the pressure of the stethoscope and by the position of the patient. It 
may be heard in the erect and disappear in the recumbent posture. 

Diagnosis. Acute pericarditis without effusion is not recognized 
generally, because it is not sought for. In the larger number of 
cases, as previously intimated, there have been no indications of dis- 
ease of the pericardium during life. If sought for, however, the diag- 
nosis is usually easy. The pericardial friction may be mistaken for 
an organic heart-murmur or for pleural or pleuro-pericardial friction. 
It is often difficult to distinguish the to-and-fro friction from the mur- 
murs of double aortic disease. If attention is paid to the general and 
local phenomena, the mistake is not likely to be made. The location 
of the murmurs in organic heart disease, the direction of the transmis- 
sion, the character of the murmur, the peculiar character of the pulse, 
and the secondary effects upon the muscles of the heart, point to the 
diagnosis of valvular lesion. The pleuro-pericardial friction which 
simulates pericardial friction usually occurs in the course of phthisis 
or pleuropneumonia. It is modified by respiratory movement : (1) It 
may disappear, or at least diminish, if the breath is held ; (2) a full expi- 
ration may cause its disappearance. While it is of cardiac rhythm it 
is modified by the respiratory rhythm, so that on inspiration it is 
usually more marked. The pleuro-pericardial friction is not so 
strikingly modified by position. Pleural Friction. This is of respira- 
tory rhythm and ceases with cessation of breathing. The pericardial 
friction persists even if the breath is held. 

Pericarditis with Effusion. 

I know of no affection which is more frequently overlooked during 
life than pericardial effusion This is because it develops without 
symptoms. In plastic pericarditis we have referred to the occurrence 
of pain. This may occur before the effusion in the latter form, but is 



PLATE XXVIII 

FIG. 1. 




"HP 



Pericarditis With Effusion. 
FIG. 2. 




Syst. ret/: 



y 



Adherent Pericardium. Chronic Left-Sided Pleurisy. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 645 

usually moderate. As with dry pericarditis, however, it may, in rare 
instances, be very severe, anginous in character, and be increased by 
pressure over the heart or on the pit of the stomach. 

The symptoms are usually due to the special character of the inflam- 
mation and the presence of fluid in the pericardium. 

1. General Symptoms. In non-suppurative cases the symptoms 
are usually cerebral. Delirium may be moderate or maniacal. It 
must not be confounded with the delirium which occurs in the course 
of acute rheumatism with hyperpyrexia. In addition, choreiform 
movements have been described. They may, however, be of rheu- 
matic origin. Other cerebral symptoms, as hemiplegia and convulsive 
attacks, occur in the course of pericarditis, probably due to an associ- 
ated endocarditis, causing embolism. In some cases albuminuria is 
found. 

The general symptoms of pericardial effusion depend upon the 
nature of the primary disease and the character of the fluid. In 
tuberculous pericarditis, emaciation, irregular fever, sweats and prostra- 
tion ensue. In purulent pericarditis there may be recurring chills with 
a temperature-range decidedly intermitting, along with other phenom- 
ena of purulent accumulation. In a case recently seen (1895) the 
patient was extremely debilitated and prostrated on account of pneumo- 
nia following influenza. He was extremely anaemic, and the blood- 
count showed diminution of red cells to one-half without other change. 
Every fourth day after a chill the temperature would rise to 103° or 
104°. A friction-sound was detected after the second chill. It disap- 
peared, but the physical signs of effusion were not positive. From 
the first the heart's action was so weak that the sounds were scarcely 
discernible. At the autopsy four or five ounces of pus were found in 
the pericardial sac. The purulent accumulation was the only lesion 
to account for the symptoms, and, we would say now, was no doubt 
a pneumococcus infection. 

2. Local Symptoms The local symptoms are due to the accumu- 
lation of fluid within the pericardium. Dyspnoea is the most common. 
The degree depends upon the amount of effusion. If the latter is 
large, there may be extreme orthopnoea ; if the effusion is present for 
a considerable time, it may give rise to no symptoms. Dysphagia. 
In large effusions this may occur, on account of pressure upon the 
oesophagus. Altered Cardiac Rhythm. The effect of the effusion upon 
the heart is to interfere with its action. Although usually regular, 
on the slightest exertion or the least excitement it palpates violently or 
becomes irregular. The heart's action is increased in frequency ; when 
the effusion is very large it may be not only irregular, but also inter- 
mittent. Aphonia may occur from pressure upon the recurrent laryn- 
geal nerve. Cough of an irritative character is sometimes noted. The 
pulsus paradoxus may be present. 

3. Physical Signs. (Plate XXVIIL, Fig. 1.) Inspection. 
There is bulging of the praecordia, particularly in children. The ribs 
and interspaces are prominent. In adults the interspaces are even with 
or distended beyond the surface of the ribs, and are sometimes widened. 



646 SPECIAL DIAGNOSIS. 

The enlargement may extend to the antero-lateral region of the left 
chest. The large effusion interferes with expansion of the lung on the 
left side, and hence movement is diminished. The epigastrium may 
be prominent, on account of displacement downward of the diaphragm 
and liver. The apex-beat is absent or faintly seen, displaced upward 
and to the left. It does not extend as near the left border of dulness 
as in dilatation. It may be seen in the fourth interspace, or a faint 
impulse may be observed in the second and third interspaces beyond 
the mid-clavicular line. 

Palpation. The impulse is feeble and diminishes in force as the 
effusion increases. The position of the apex as determined by inspec- 
tion is confirmed. Ewart points out that the first rib is palpable at 
its sternal attachment in pericardial effusion. The pericardial fric- 
tion which may have been present at first disappears with the effusion. 
Fluctuation may be detected in large effusions. The liver in large 
effusions is depressed and readily palpable. 

Percussion. The area of precordial dulness is increased. There 
is increase of the lateral boundaries and great increase of absolute dul- 
ness. The increase of area is usually in all directions, although in- 
crease of the dulness upward and to the left only is very common. It 
may extend as high as the second rib. As pointed out by Rotch, 
dulness in the fifth right interspace in the angle formed by the right 
border of the heart and the right lobe of the liver is common in effu- 
sion. It may be an early sign of effusion. Ebstein calls this region 
the cardio-hepatic triangle, and points out that the dulness is absolute 
in effusion, although impaired in normal states because of proximity to 
the liver. 

Pulmonary resonance is modified posteriorly in large effusions. The 
dulness in large effusion includes the axillary region, so that it may 
simulate a pleural effusion. The dulness, however, does not extend 
below the eighth rib in this region, whereas, in pleural effusion, dul- 
ness always extends to the bottom of the pleural sac. In a large peri- 
cardial effusion the semilunar space of Traube is obliterated. 

Auscultation. The sounds are feeble and distant. They may be 
scarcely heard at all over the precordial region. The sounds at the 
base of the heart are diminished in intensity. If a friction-sound was 
heard at the beginning, it disappears entirely as the effusion is poured 
out. In moderate effusions the friction may be heard when the erect 
posture is assumed. 

It must not be forgotten that the physical signs, and especially the 
change in impulse and the area of precordial dulness, are modified by 
the position of the effusion. Accumulations occur behind the heart or 
above it, and in these situations interfere least with the displacement 
or the enfeeblement of the apex-beat. The area of dulness, however, 
is increased upward. 

In cases of large effusion the compression of the lung may cause 
bronchial breathing to be heard posteriorly or in the axillary region. 
In a case under my care the diagnosis of pericardial effusion was 
readily made, but the enormous effusion so markedly simulated an 



DISEA SES OF HE A BT, BLO OD VESSELS A ND MEDIASTIN UM. 647 

effusion into the pleural cavity that both serous cavities were believed 
to contain fluid. Aspiration was performed in the sixth interspace in 
the anterior axillary line. The fluid was removed from the peri- 
cardium , as was afterward determined. During life pressure-signs — 
laryngeal stridor, difficulty of deglutition, and extreme dyspnoea — were 
present. Early vomiting, epigastric pain and tenderness, slight de- 
lirium, albuminuria, and an excessively weak, rapid pulse occurred in 
the course of the disease. The patient was a male, twenty years of 
age. The effusion was due to tuberculous pericarditis, secondary to 
tuberculosis of the bronchial glands. The physical signs were prom- 
inence of the prsecordia ; bulging of the interspaces on the left side ; 
diminished expansion of the left side — anteriorly, laterally, and poste- 
riorly ; increased expansion at the extreme apex of the lung. The 
vocal fremitus was absent below the second interspace in front, below 
the third in the axilla, and diminished below the spine of the scapula 
behind. There was dulness from the second left rib in front to 
the margin of the thorax ; from the fourth to the eighth rib in the 
axilla ; below the eighth rib, tympany. The dulness extended be- 
yond the margin of the sternum on the right side, almost to the 
right nipple-line, in the fourth and fifth interspaces. Posteriorly, dul- 
ness from the middle of the scapula to the base of the thorax, except 
along the vertebrae, where, from the seventh to the ninth rib, there 
was tympany. The physical signs of pericardial effusion on auscul- 
tation were marked. In the axilla the breath-sounds were absent. 
There were bronchial breathing and bronchophony behind from the 
spine of the scapula to the base along the vertebra?. They were most 
marked opposite the angle of the scapula, where the above-noted tym- 
pany was observed. In the mid-scapular line the breath-sounds dimin- 
ished from above downward, and were absent at the base. It is seen 
that the physical signs of pleural effusion were present posteriorly and 
laterally, due to the enormous effusion. At the autopsy the pericar- 
dium was found to contain sixty-four ounces of fluid. 

Pleural effusions may be excluded in similar cases by the absence 
of dulness in the axillary region below the eighth rib ; by increase in 
dulness beyond the right edge of the sternum ; and, at the same time, 
by the absence of signs indicating dislocation of the heart to the right. 

Diagnosis. Pericardial effusion must be distinguished from dilata- 
tion of the heart. Although feeble and diffuse, the expansile shock of 
the impulse is more distinct than in dilatation. This distinction is not 
generally difficult if the patient has been under observation during the 
development of the disease. The impulse is not always absent in dila- 
tation. Fluctuation may be detected. The area of dulness in dilata- 
tion does not extend upward except in cases in which the right auricle is 
enlarged. The dulness does not extend downward in dilatation with- 
out a similar displacement of the apex impulse. The shape of the 
dulness differs. In dilatation the dulness is square in shape ; in 
effusion it is triangular or pear-shaped, with the base downward. In 
dilatation the sounds are accentuated, and are of a valvular character ; 
in effusion they are muffled. Dilatation does not cause the pressure- 



648 SPECIAL DIAGNOSIS. 

symptoms that occur in effusion. In pericardial effusion Bamberger's 
sign is of importance. When the patient is sitting upright an area of 
dulness about the size of a silver dollar can be marked out at the 
angle of the scapula. Over it, dulness, increased fremitus, and bron- 
chial breathing are made out. If the patient leans forward, the dulness 
and the other signs of consolidation disappear, to return when he sits 
upright. In children pseudo-pleuritic signs are often present poste- 
riorly — dulness, pleuritic friction, broncho-cegophony — but will disap- 
pear if the patient is put in the knee-chest posture. It is of diag- 
nostic significance to have change of the rhythm and the character of 
the sound from day to day, or of its degree of loudness on movement 
of the patient. 

In pericarditis with effusion, after its absorption, the friction-sound 
may return. Often it may disappear entirely and all signs of pericar- 
dial inflammation subside. In plastic pericarditis and pericarditis with 
effusion adhesion of the two layers of the pericardium may take place. 

Effusions into the pericardial sac of serum, of blood, or of air, may 
take place without previous inflammation. 

Hydro-pericardium. This may occur in the course of general 
dropsy from kidney or heart disease. It may not prove fatal of itself, 
but when associated with effusion in the pleural sac it contributes to 
the orthopnoea, which may cause death. Rarely after scarlet fever, 
effusion into the pericardial sac may be the only dropsical symptom. 
The physical signs are those of effusion. It is not attended by fever. 
It is frequently overlooked, because investigation beyond the pleura 
is not made after an effusion into that cavity has been found. 

Haemo-pericardium. This occurs on account of rupture of an 
aneurism of the first part of the aorta, of the heart itself, or of the 
coronary arteries. Wounds of the pericardium and heart cause hsemb- 
pericardium. The extension of the ulceration of malignant endocar- 
ditis to the surface may cause gradual effusion of blood. (See Keat- 
ing, Transactions of the Philadelphia Pathological Society.) The physical 
signs are those of effusion. Death usually takes place before there has 
been time to make a sufficiently accurate examination to determine its 
presence. Rapid heart-failure due to compression is the cause of death. 
In the case referred to above, and in cases of rupture of the heart, the 
patient may live for many hours with dyspnoea and progressive weak- 
ening of the heart. In tuberculosis and cancer the effusion is fre- 
quently blood-stained. 

Pneumo-pericardium. This occurs very rarely, and is due to per- 
foration from without by a stab-wound, or perforation from the lung, 
oesophagus, or stomach. A purulent exudation may undergo decom- 
position, causing an accumulation of gas. If it arises from perforation, 
acute pericarditis is set up. The accumulation of gas causes tympany 
over the movable area of percussion-dulness. The most striking sign 
is noted on auscultation. Churning, splashing, or metallic sounds are 
heard,' drowning the feeble heart-sounds. Death usually occurs quickly. 

Adherent Pericardium. (Plate XXVIIL, Fig. 2.) Chronic adhe- 
sive pericarditis may follow the acute form or, particularly if tubercu- 



DISEASES OF HEART, BLOODVESSELS AND MEDLASTINUM. 649 

lous, develop independently and progress slowly. Inspection and Palpa- 
tion. Indrawing of the interspaces may be seen at the time of the systole 
of the ventricles ; even the ribs are said to be drawn in. This indrawing 
is most marked at the apex, and must not be confounded with the retrac- 
tion that occurs in the third and fourth interspaces with the ventricular 
systole. The recession is synchronous with the systolic shock. In some 
cases the systolic movement over the prsecordia is of an undulatory 
character. Walter Broadbent calls attention to systolic retraction of the 
back in the region of the eleventh or twelfth rib as a valuable sign. 
The apex is displaced outward and the area of impulse is increased. The 
increase in area of impulse is due to the hypertrophy which always 
attends universal adhesion of the pericardium. After the systole there 
is frequently felt a quick rebound, known as the diastolic shock, which 
is said to be characteristic of pericardial adhesions. 

In pericardial adhesions Friedreich's sign, collapse of the cervical 
veins, during the diastole of the heart, is seen. We may also see in- 
spiratory swelling (Kussmaul). In addition, the pulsus paradoxus 
is significant of the presence of pericardial adhesions, or rather of the 
dilatation that succeeds the adhesions. The pulse is small and feeble 
during inspiration, assuming greater strength during the period of ex- 
piration. 

Percussion. The area of cardiac dulness is increased usually up- 
ward, extending as high as the first interspace. The area of dulness 
is frequently not modified by respiration — that is, it is not lessened 
when the patient takes a full breath, when the lungs should expand 
over the precordial region. This is particularly the case when there 
is pleuritis associated with pericarditis, a common association in the 
lar^e majority of cases. 

Auscultation. On auscultation the signs vary. The sounds are due 
to hypertrophy or to dilatation ; and it must not be forgotten that 
they frequently arise on account of pericardial adhesions. In the 
former condition the first and second sounds are accentuated ; in the 
latter, a murmur may be heard at the apex, loud and systolic in time. 

In pericardial adhesions the physical signs depend upon the condi- 
tion of the heart muscle at the time of the examination. At first we 
have the physical signs of hypertrophy, with retraction of the inter- 
spaces, particularly at the apex, or the space at the xiphoid cartilage. 
This is particularly the case in young subjects. In the later period of 
the disease the physical signs of dilatation arise, indicated by increase 
in transverse dulness, enfeeblement of impulse and of sounds, with the 
development of a murmur at the apex, undulation of the veins in the 
neck, and the pulsus paradoxus. The physical signs of associate pleu- 
risy aid in the recognition of adherent pericardium. Diminution of 
the breath-sounds, increase in the area of cardiac dulness, lessened 
fremitus in the neighborhood of the heart pointing to pleural thickening, 
are associate evidence. Sansom considers the presence of pulmonary 
tuberculosis of value, as pointing to the occurrence of pericardial adhe- 
sions, for the associate pleural adhesions are likely to be attended by 
tuberculous pericarditis. 



650 SPECIAL DIAGNOSIS. 

I have learned to suspect adhesive pericarditis in a young subject 
the victim of valvulitis, when the symptoms do not yield to treatment — 
in short, when the heart is not affected by digitalis. Unfortunately, 
the physical signs are often not conclusive. 

The subjective symptoms of adherent pericardium are those of dilata- 
tion or hypertrophy of the heart, whichever one of the two is in excess. 

Indurative mediastino-jiericarditis with adhesion may occur with or 
without fibrous inflammation and adhesion of the structures in the 
anterior mediastinum. The pericardium is adherent and thickened. 
Rarely the anterior mediastinum alone is a mass of fibrous inflamma- 
tion. Peritonitis and perihepatitis may be found. The entire process 
may be tuberculous. The symptoms are dyspnoea, venous engorgement, 
cyanosis, enlargement of the liver, ascites, and dropsy. The physical 
signs are those of extreme cardiac dilatation ; the pulsus paradoxus ; 
collapsing jugular veins during diastole, due to the dragging upon the 
innominate veins and cava by the fibrous adhesions, or to stretching 
and narrowing of the aortic arch by these adhesions ; or inspiratory 
swelling of the veins of the neck. A friction-sound, systolic in time, 
heard over the sternum, increased when the arm is held up — mediasti- 
nal friction, so called, has been described in this affection. 

It usually follows an acute chest-affection, occurs most frequently in 
young adults, and in males. It should also always be suspected in 
cases of dilatation and valvulitis in which compensation does not take 
place, notwithstanding the best treatment. 

Endocarditis. 

Endocarditis may be acute or chronic. In either form it is usually 
secondary. The acute form is divided into simple and so-called malig- 
nant, infectious, or mycotic endocarditis. 

Simple Endocarditis. Acute endocarditis rarely occurs primarily. 
It usually occurs secondarily to general morbid processes. The patho- 
logical antecedents are acute rheumatism, tonsillitis, whooping-cough, 
scarlet fever, gonorrhoea, rarely smallpox and typhoid fever. It is of 
common occurrence in pneumonia and tuberculosis. It is frequent in 
chorea. In the simple form it occurs in septic inflammations and in 
debilitating diseases, as cancer. It may occur in gout and develop in 
the course of Bright' s disease. 

Symptoms. The symptoms of simple endocarditis are scarcely ob- 
served during the early course of the disease. The process is latent, 
and there are no indications of cardiac disease. The physical signs 
alone betray its presence. Unless these are sought for the disease is 
overlooked. The subjective symptoms are negative. In the course 
of rheumatism or chorea, or during convalescence from the former, the 
patient may complain of palpitation, and increased frequency and 
irregularity of the heart. At the same time there may be a rise in 
temperature, not attended by any increase of the rheumatic symptoms, 
which should call attention to the cardiac complication. The rise is 
not marked, and may not assert itself during the severity of the disease. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 651 

Physical Signs. On examination a murmur is detected in one of 
the cardiac areas. The murmur is soft, low in pitch, and follows the 
laws of transmission, according to its situation. Instead of a distinct 
murmur a roughening of the first sound alone may be heard. Pre- 
ceding the murmur the heart's action may be quickened and arhythmi- 
cal ; the first sound may change in character from day to day or be 
accentuated ; the second reduplicated at the apex and accentuated. 
The new sounds may disappear at first when the patient sits up ; later 
they persist. The murmur must not be mistaken for the murmur at 
the apex in cardiac dilatation ; or the murmur which may be heard in 
the course of fevers ; or the murmur of anaemia, which may rapidly 
develop in rheumatism and other affections. 

Malignant Endocarditis. Unlike simple endocarditis, the malig- 
nant form very rarely develops in the course of rheumatism and 
chorea. (See the Infections.) It occurs more frequently in pneumonia 
than in any other disease. It arises in the course of erysipelas, septi- 
caemia, puerperal fever, and gonorrhoea. It may occur in dysentery. 
It is usually a streptococcus infection. 

Symptoms. The symptoms are (1) those due to the morbid process 
— the infection ; (2) the physical signs ; (3) those due to emboli. The 
general symptoms due to the specific morbid process are septic in nature. 
The febrile phenomena may be one of four groups : (1) The fever is 
paroxysmal. Chills and fever occur daily or at intervals of two or 
three days, resembling types of malarial fever. Each paroxysm is 
attended by profuse sweats. Rapid exhaustion ensues. The fever, 
instead of being distinctly intermittent, may be irregularly intermit- 
tent. (2) The fever is excessive and continued, and a typhoid state 
frequently sets in. The temperature is irregular ; extreme prostration, 
low delirium, sordes, subsultus, and other symptoms of that state arise. 
(3) The fever is moderate and continued. Physical examination, how- 
ever, reveals the presence of marked endocarditis. In this group 
chronic heart disease has usually preceded the affection. The duration 
may be prolonged. (4) The fever may be remittent. Petechial rashes 
and erythema are common, so that, as pointed out by Osier, the disease 
may resemble the eruptive fevers. The sweating is profuse, contrib- 
uting to the profound exhaustion which usually ensues. A septic 
diarrhoea occurs. In a few rapidly fatal cases jaundice has occurred. 
Again, the symptoms may be almost exclusively cerebral, resembling 
cerebro-spinal or basilar meningitis. 

The embolic phenomena are due to escape into the blood-current of soft 
vegetations from the valves of the left heart (for the right heart is 
rarely affected), which are carried by the blood-stream into distant 
points of the circulation. Emboli occur in the brain, producing 
aphasia or hemiplegia ; they occur in the retina, causing some com- 
plaint as to vision, but are accurately recognized by ophthalmoscopic 
examination. They occur in the kidneys, producing bloody urine and 
renal pain. In nearly all cases the spleen is the seat of embolism, and 
in some instances infarctions may take place in this organ alone. The 
spleen is always enlarged, and the infarct may cause pain and increased 



652 SPECIAL DIAGNOSIS. 

tenderness on pressure. Emboli in the skin and mucous membranes 
present the most striking phenomena. The hemorrhages underneath 
the skin are minute. They are seen in the extremities, but may also be 
found on the trunk. They occur in the mucous membranes, as those of 
the mouth and tongue. They are seen in the bulbar conjunctivae, and 
in the conjunctivae of the lids. 

Physical Signs. Repeated examinations are necessary in some cases, 
to determine the presence of a murmur, or to decide whether a previ- 
ously existing organic lesion is the seat of an acute process. Varia- 
tions in the character of the murmur from day to day are characteristic 
of malignant endocarditis. In organic heart disease with dilatation and 
failure of compensation, irregular fever followed by embolic phenom- 
ena points to the occurrence of an infectious process on the antecedent 
valvulitis. 

Diagnosis. This form of endocarditis is of infectious origin. The 
diagnosis rests upon proof that an infection is present, and is made by 
the methods described in Chapter XIX., Part I., which should be 
reviewed by the reader. The history of an infection in some part of the 
body is most important in the diagnosis. The presence of the infection, 
as well as its nature, may be disclosed by an examination of the blood. 
When embolic phenomena are present the diagnosis is made without 
much difficulty. The more pronounced general symptoms distinguish 
it from simple endocarditis. The temperature-range, the septic and 
typhoid symptoms, belong to the malignant form. The more pro- 
longed cases with moderately continuous fever, without apparent 
primary cause, are frequently confounded with typhoid fever. This is 
readily appreciated when the symptoms of the two are compared. In 
both there is fever of a continued type, with the symptoms of the 
typhoid state, including delirium. In both there are enlargement of 
the spleen, diarrhoea, and abdominal tenderness. In both there may 
be infarctions, although they are extremely rare in typhoid fever, and 
only occur late in the disease. In both there is progressive exhaus- 
tion. But in endocarditis the onset may be more abrupt. The fester 
does not present the regularity of type that is seen in the development 
of typhoid. In endocarditis there is more chest oppression and 
dyspnoea early in the disease than in typhoid fever. In endocarditis 
the source of the infection may be discovered in the genito-urinary 
organs, the lungs, the bones, etc. The diazo-reaction is found in 
typhoid fever after the fifth day, but rarely, if ever, in endocarditis. 
The results of bacteriological examination, and especially of serum 
diagnosis, distinguish the two affections. This ought to be of value in 
endocarditis, because the process is usually due to a staphylococcus or 
streptococcus infection. Either micro-organism may be found in any 
suppurations which may possibly be present or in the blood. In a child 
recently seen by me in the relapse of an attack of typhoid fever, malig- 
nant endocarditis was thought to be present, because of a loud and rough 
murmur at the pulmonary orifice. Fortunately the murmur was present 
in the apyretic period, and as the child was anaemic its exaggeration 
was ascribed to the fever. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 653 

Malignant endocarditis must be distinguished from cerebrospinal 
fever, and from smallpox of the hemorrhagic type. We must rely on the 
local cardiac symptoms and physical signs, and the preponderance of 
these over the other symptoms. Of course, the prevalence of an 
epidemic and a history of exposure are of service in the distinction 
between the diseases. Examination of the blood excludes the forms 
of malaria which formerly were mistaken for endocarditis. 

Chronic Endocarditis. Chronic endocarditis may follow the acute 
form or develop in the course of atheroma or of endarteritis due to 
alcoholism, the poison of syphilis or of gout. If associated with endar- 
teritis, the endocardial change may be part of the general degenerative 
changes which occur in the aging process. It may be of dynamic 
origin, often following prolonged heavy muscular exertion, by which 
the valves, particularly at the aortic orifice, have been subjected to 
strain. The process is slow and insidious, and leads to the changes in 
the valve-segments which constitute chronic valvular disease. 

Symptoms. The symptoms of chronic, or sclerotic, endocarditis are 
the symptoms of chronic valvular disease. Insufficiency or obstruc- 
tion, or both combined, take place at the affected valve-orifice. The 
outflow of blood is retarded in obstruction. Backward flow, or regur- 
gitation, takes place in insufficiency in the opposite direction from 
the normal blood-current. When there is obstruction hypertrophy 
usually develops to meet it. If the obstruction is moderate, and the 
person remains in good health, the hypertrophy is sufficient to over- 
come the obstruction. In this manner the effect of the valve lesion is 
compensated. On the other hand, when blood is permitted to flow 
by regurgitation backward into the cavity — that is, in the opposite 
direction to its usual course — it meets a blood-current flowing to this 
cavity in the normal direction, and the result is overdistention, or over- 
filling, of the cavity. Dilatation ensues, and may persist. If the re- 
gurgitation takes place suddenly, the dilatation continues ; if gradually, 
as in chronic endocarditis, the dilatation is attended with hypertrophy. 
Thus, when there is regurgitation from the left ventricle into the left 
auricle, on account of incompetency at the mitral orifice, the auricle 
becomes overdistended with blood, for it is filling with blood from the 
pulmonary veins at the same time. This overdistention can only be 
overcome by some hypertrophy. When this is not sufficient the blood 
is obstructed in the pulmonary circulation, with the consequences here- 
after to be mentioned. 

The symptoms of chronic endocarditis are latent if the lesions are 
compensated ; if not, symptoms of failure in compensation occur or 
dilatation of the heart arises. The physical signs are those of chronic 
valvulitis. The character of the signs depends upon the lesion of the 
affected valve. 

Disease of the Coronary Arteries. 

Atheroma, associated with the process in other vessels,, or distinctly 
localized to the coronary arteries, affects these vessels. Its causal 
factors are those of endarteritis elsewhere. Its influence on the nutri- 



654 SPECIAL DIAGNOSIS. 

tion of the heart, either by sudden obstruction of the vessels by an 
embolus or by their gradual closure, is apparent. 

Symptoms. If an atheromatous coronary artery is suddenly ob- 
structed by an embolus, death may be immediate. This is a common 
cause of sudden death. In other instances thrombosis may take place, 
followed by anaemic infarction, myocarditis, and mural aneurism. In 
this class of cases the onset of the symptoms may be sudden. Praecor- 
dial oppression or angina pectoris may be the first indication. Succeed- 
ing this, dyspnoea, dilatation of the heart, and venous stasis occur. The 
presence of an aneurism may be made out. The heart's action is per- 
sistently rapid and may be arhythmical. If there has not been pre- 
vious valvulitis, no murmurs are heard until dilatation ensues. The 
patient may live three or four weeks, or as many months. 

In a third group of cases occlusion, either from the endarteritis or 
from a slowly forming thrombus, is so gradual as to lead to myocar- 
ditis only with the attending symptoms. 

Diagnosis. Unfortunately, too often the diagnosis can only be pro- 
visional. Sudden death may be attributed to coronary artery disease 
if there has been a history of previous attacks of angina, if there is 
evidence of arterial disease elsewhere, and if dyspnoea or anginoid 
symptoms preceded the fatal termination. Thrombosis, secondary to 
atheroma, may be suspected if a patient, in whom there is no valvular 
disease, no pulmonary or renal disease, is seized with angina pectoris 
or dyspnoea ; providing tachycardia and arhythmia follow, and in a 
short time cardiac dilatation, venous stasis, etc. In a male, aged forty- 
three years, Avithout syphilis, but with a history of antecedent rheuma- 
tism, an attack of angina pectoris followed some unusual exertion. 
Prior to this he had been in the most perfect health. The attack was 
followed by dyspnoea and remarkably rapid heart-action without appar- 
ent cause. The physical signs of acute congestion of the lower lobe of 
the right lung followed within twenty-four hours of the attack of angina. 
The patient was ill three months. He improved somewhat, but rapidity 
of the heart's action and some stasis in the lung persisted. Gradually 
cardiac dilatation ensued, with a murmur in the tricuspid area. Death 
took place from pulmonary congestion. At the autopsy the coronary 
arteries were atheromatous ; the left was filled with an old thrombus ; 
there was extensive myocarditis and an aneurism of the left ventricle. 

In another case, male, aged seventy-two years, with general atheroma 
but no valvulitis, sudden precordial distress, tachycardia, and persist- 
ent dyspnoea were followed by cardiac dilatation, mitral incompetency, 
general anasarca. 

I have said elsewhere, a persistently rapid pulse, uninfluenced by 
digitalis, indicates pericardial adhesion in the young ; the same pulse 
uninfluenced by treatment points to coronary artery disease in the 
middle-aged and senile. 

Myocarditis. 

Myocarditis may be acute or chronic. The entire muscle or only 
a portion may be affected. General myocarditis is always acute. The 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 655 

local form may be acute or chronic, depending upon the degree of 
the primary cause. The local variety is usually due to a thrombus 
in the terminal endings of the coronary artery, which cuts off the 
blood-supply. The changes are those of myocarditis, to which may be 
added necrosis of small areas and the development of aneurism. 
Etiology. Pathological antecedents of acute general myocarditis are 
the fevers, particularly typhoid and typhus fever, pneumonia, diphthe- 
ria, and septic fevers generally. Chronic myocarditis is usually asso- 
ciated with atheroma, one of the causes of which occurs in the later 
stages of Bright' s disease. (See Atheroma.) The result of myocar- 
ditis, when acute, is dilatation of the heart, fatty heart, or aneurism of 
the heart. Chronic myocarditis is followed by fatty heart, by dilata- 
tion, by the so-called fibroid heart or fibrous myocarditis, and by aneu- 
rism. The above facts in etiology are important in diagnosis. 

Symptoms. The symptoms of acute myocarditis are vague. In 
the course of, or in the convalescence from, an infection the patient may 
complain of some oppression in the prsecordia and suffer from dyspnoea ; 
attacks of syncope may occur, and sighing may be frequent. The 
pulse becomes more rapid and weak, but is usually not irregular. The 
circulation is much depressed, the hands may be cold, the face pallid. 
These symptoms may be accounted for by the extreme exhaustion alone 
that follows fever. No doubt some myocarditis accounting for the 
symptoms exists in all cases, particularly if there is prolonged high 
temperature. Often the patient does not complain of any cardiac symp- 
toms. Death takes place suddenly, either in the course of the dis- 
ease or after it has spent its force, from acute dilatation or cardiac 
paralysis. This is particularly true in pneumonia and diphtheria. In 
the latter affection the sudden appearance of cardiac symptoms, dysp- 
noea, cyanosis, and cold extremities may be due to paralysis of the 
heart. 

Physical Signs. Enfeeblement of the heart-sounds, sometimes with 
accentuation of the mitral first sound, is observed. The impulse and 
apex-beat are scarcely perceptible, or absent altogether. If acute dila- 
tation supervenes the area of dulness may be ii: creased. 

The symptoms of chronic myocarditis are obscure and indefinite, and 
in the majority of cases depend upon the secondary changes that have 
taken place in the heart muscle. If there is atrophy of the fibroid 
heart, the pulse is feeble, slow, and irregular. It may be as slow as 
thirty or forty beats to the minute. Irregularity is not necessarily 
present, but intermittency is of frequent occurrence. The patient com- 
plains of dyspnoea aggravated by exertion. Attacks of angina pectoris 
are likely to occur. The symptoms of dilatation of the heart may 
ensue later, with oedema, cyanosis, and congestions. A symptom-com- 
plex, known as the Stokes- Adams syndrome, is often seen, character- 
ized by dyspnoea, coma, and slow pulse — a pseudo-apoplexy. In fatty 
degeneration of the heart the pulse is increased in frequency ; there are 
cardiac irregularity, palpitation, and dyspnoea. These, however, are also 
the symptoms of dilatation, which usually succeeds the degeneration. 
The heart-sounds are weak. If dilatation has set in, a murmur is heard 



656 SPECIAL DIAGNOSIS. 

at the apex, with gallop-rhythm of the heart. In fatty degeneration 
attacks of collapse with slow pulse are common. Shortness of breath 
on exertion may occur. Cardiac asthma occurs at night, and sighing 
and yawning are of frequent occurrence during the day. The patient 
usually sleeps badly. The cerebral functions are more or less in abey- 
ance, the action of the mind is sluggish ; the patient may have delu- 
sions or become maniacal. Cheyne-Stokes breathing was formerly 
thought to be of diagnostic significance. 

Chronic myocarditis must be distinguished from fatty overgrowth of 
the heart. This cardiac change is frequently seen in brewers and 
saloon-keepers, and is usually associated with obesity. The pulse may 
be feeble, the heart-sounds weak and muffled. The patients are sub- 
ject to attacks of asthma, and frequently have bronchitis and emphy- 
sema. Vertigo is of common occurrence. Death may occur during 
syncope. 

Aneurism of the Heart. 

Aneurism of the valves, following endocarditis, cannot be recognized 
during life. Aneurism of the walls usually results from chronic myo- 
carditis. The aneurism develops in the left ventricle at the apex. 
The symptoms are indefinite. In rare cases a marked bulging has 
been noted in the region of the apex, and the tumor may perforate the 
chest-wall. A projection beyond the normal line of cardiac dulness 
may be detected by stethoscopic or plessimetric percussion. The 
symptoms are those of myocarditis and of dilatation of the heart. 

Rupture of the heart is one of the causes of sudden death, often 
without previous symptoms. The accideut takes place during exer- 
tion. Quain collected one hundred cases, in seventy-one of which 
death took place without previous warning. In other instances there 
was a sense of anguish, and suffocation in the cardiac region. The 
physical signs of slowly developing pericardial effusion may be ascer- 
tained if the leakage from rupture is slow in progress. 

Chronic Valvular Disease. 

Valvular disease includes valvulitis and valvular incompetency ; 
there is either obstruction or regurgitation at the orifices affected. 
Valvulitis may exist with or without symptoms ; valvular incompe- 
tency is always accompanied by symptoms. Valvulitis implies organic 
disease of the valves ; valvular incompetency, regurgitation through 
orifices, the valves of which cannot close it, but they may or may not 
be diseased. Valvulitis may be recognized by physical signs of (1) 
the lesion, (2) the secondary effects of the lesion on the heart and cir- 
culalion — hypertrophy or dilatation. Valvular incompetency occurs 
usually in dilatation, and may be secondary to valvulitis. It is recog- 
nized by both signs and symptoms. Valvular disease is without symp- 
toms as long as the heart-muscle enlarges sufficiently to keep in balance 
the impaired circulation ; compensation is then said to be complete. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 657 

When compensation is broken we then have the subjective symptoms 
enumerated above, all in consequence of dilatation of the heart. It 
may be said that valvulitis is of no significance as long as compensation 
is perfect. To review — valvulitis may be attended by physical signs 
in the heart and vessels only, or by its own physical signs, the physical 
signs of dilatation, and the symptoms of the latter. In the considera- 
tion of valvular disease it is more profitable to take up the symptoms 
of each valve-lesion, bearing in mind that two or more of the valves 
may be diseased at the same time, or that both obstruction and regur- 
gitation may be present at the same time at the same valve-orifice. 

Aortic Regurgitation, Insufficiency or Incompetency. This may 
exist for a long time without presenting any symptoms. It occurs 
more frequently in men than in women, and is more common in the 
later periods of life. It may be due to congenital malformation, to 
acute endocarditis, or, as is most frequently the case, to chronic endo- 
carditis, particularly when it follows strain or undue exertion ; alco- 
holism and syphilis are also frequent antecedents. In rare cases it 
follows rupture of the valves. Relative insufficiency or incompetency 
is of very rare occurrence. Insufficiency is frequently combined with 
obstruction. 

On account of regurgitation, or insufficiency, at the aortic orifice the 
blood falls directly into the left ventricle during the diastole. There 
is, first, a relative diminution in the amount of blood in the artery ; 
and, second, an increased amount of blood in the ventricle, because the 
regurgitated column of blood meets the blood from the auricle which 
is filling the chamber at the same time. Dilatation of the left ventri- 
cle ensues, and is followed by hypertrophy. Dilated hypertrophy thus 
arises. The heart becomes enormously enlarged. This is one of the 
conditions in which enormous cardiac enlargement takes place — so- 
called cor bovlnum. If this valve-lesion occurs at the period of life 
and from the causes above mentioned, it is attended by more or less 
sclerosis of the arteries. 

Symptoms. They may be entirely absent as long as perfect com- 
pensation exists. This is particularly the case if there is but little 
general arterial sclerosis. Coincident lesions of other valves tend to 
break the compensation. The earlier symptoms are those due to 
arterial anaemia, particularly anaemia of the brain. They are head- 
ache, dizziness, and flashes of light before the eyes. The patient has 
an anaemic appearance, and soon begins to suffer from shortness of 
breath. This at first develops upon slight exertion. Palpitation and 
oppression about the chest are complained of, readily excited by undue 
exertion. Pain is a common symptom. It may be in the region of 
the praecordia, of a dull, aching character, and radiate to the neck and 
down the arms, particularly on the left side. The anginoid pains may 
be followed by attacks of true angina pectoris. The latter are more 
common in aortic regurgitation than in any other valve-lesion. 

As compensation fails venous stasis occurs and the dyspnoea in- 
creases. The latter is worse at night and compels the patient to sleep 
in a semi-erect posture. Congestion of the lungs takes place, giving 
rise to cough. Hemorrhage occurs, but not so frequently as in mitral 

42 



658 SPECIAL DIAGNOSIS. 

disease. (Edema of the feet sets in, but general anasarca is not com- 
mon. GEderna of the feet may be due to the attendant anaemia. 

In aortic insufficiency sudden death is of common occurrence. This 
may take place at night during an attack of dyspnoea, or occur sud- 
denly upon the slightest exertion, such as straining at stool, or ascend- 
ing a height, or walking more quickly than usual. 

The Physical Signs of Aortic Regurgitation. (Plate XXIX., Fig. 1.) 
Inspection. The apex beat is downward, outward, and to the left. It 
may be as low as the seventh interspace, and as far out as the anterior 
axillary line. The area of cardiac impulse is increased. It occupies 
the whole prsecorclia, and heaving of the lower half of the chest may 
be seen. In young subjects there is precordial bulging. 

Palpation. The impulse is strong and heaving. After compensa- 
tion fails it is indefinite and wavy. A thrill, diastolic in time, may 
be felt if the hand is placed about the middle of the sternum. 

Percussion. The area of dulness is increased. The extent is greater 
than that in any other valve-lesion, and the enlargement is more par- 
ticularly downward and to the left. 

Auscultation. At the second costal cartilage on the right a murmur 
is heard, diastolic in time. This may be its seat of maximum inten- 
sity. (See Fig. 175.) It is transmitted along the course of the ster- 
num toward the apex. In some instances the seat of maximum intensity 
is at the fourth left costal cartilage, or even at the apex. The second 
sound is absent in the large majority of cases. In some instances, 
however, both murmur and second sound may be heard at the same 
time. Other murmurs also may be associated with aortic regurgita- 
tion, not always due to disease of the aortic valves : 

1. A systolic murmur at the second costal cartilage on the right, 
transmitted into the vessels of the neck, short, rough, and high in 
pitch. It is due to roughening of the valve-segments, or to atheroma 
of the aorta. 

2. A murmur at the apex, rumbling in character, localized to this 
area, usually presystolic in time. It is the murmur described by 
Flint, who attributes it to flapping of the mitral segments, which 
during diastole are not forced back against the heart-wall, on account 
of the dilatation of the ventricle. They remain in the blood-current 
and produce relative narrowing. 

3. A systolic murmur in the mitral area, low in pitch, due to dila- 
tation. This occurs when failure in compensation takes place. 

Examination of the Arteries. Pulsation of the peripheral vessels is 
more common in aortic regurgitation than in any other valve-lesion. 
The carotids throb, the temporals pulsate, the brachial and radial arte- 
ries are conspicuous. Pulsation of the retinal arteries is seen with the 
ophthalmoscope, and has often led to the recognition of the disease by 
the ophthalmologist who had been consulted for other conditions. The 
pulsation is of a jerking character ; in the neck it may simulate the 
pulsation of an aneurism. The aorta can be seen and felt at the supra- 
sternal notch. The abdominal aorta pulsates vigorously in the epigas- 
trium. The pulse is significant in aortic regurgitation. The so-called 
water-hammer, or Corrigan's, pulse is observed. The pulse is quick 



PLATE XXIX. 



FIG. 1. 



I A IV^^MHv 



w ^ ^"" yfl " iiife^- 




Aortic Regurgitation. 
FIG. 2. 



W/ 




v x > 



\ ^O 



Aortic Obstruction. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 659 

and jerking, and after striking the finger immediately recedes. It is 
most marked when the arm is held up. On auscultation of the arteries 
double murmurs may be heard in the carotids and subclavians, and in 
rare instances they are present in the femorals. (See Pulse.) 

The Capillary Pulse. This is seen beneath the finger-nails, or on the 
surface of the skin, as the forehead, when a line is drawn across it. The 
hyperemia produced on either side of the line becomes alternately red 
and pale. Capillary pulse also occurs in anaemia, and at times in 
neurasthenia. 

Aortic Obstruction. Aortic obstruction occurs in the aged, and 
with atheroma of the arteries. It causes some diminution in the 
amount of blood in the peripheral circulation, resulting in poor nutri- 
tion and the development of anaemia. 

Symptoms. Anaemia develops first, and embolic phenomena may 
occur later. The symptoms may be latent until the occurrence of em- 
bolism. This accident is not uncommon, on account of the position of 
the aortic valve. The emboli are distributed throughout the arterial 
circuit, and may lodge in the brain, kidneys, or spleen. When the 
obstruction is pronounced the blood-supply in the arteries is dimin- 
ished. Cerebral anaemia takes place, causing dizziness and fainting. 
Sleep is more disturbed than in other valve affections, because of the 
cerebral anaemia. Palpitation and cardiac pain occur, but are not so 
common as in aortic regurgitation. When compensation fails, dilata- 
tion of the left ventricle ensues, followed by pulmonary congestion 
and stasis in the systemic circulation. 

The Physical Signs. (Plate XXIX., Fig. 2.) There is hyper- 
trophy of the left ventricle. Inspection. The apex-beat is displaced 
downward and outward. The impulse is strong during the period of 
hypertrophy. When compensation fails the physical signs of dilatation 
ensue. In many cases, from the very first, there may be considerable 
hypertrophy without the visible impulse, because of associate emphy- 
sema, which is common to old men with this lesion. 

Palpation. At the base of the heart, and in the aortic area, a thrill, 
systolic in time, may be felt. When present, it is usually very distinct, 
and is transmitted along the course of the vessels. The impulse is slow 
and heaving, if hypertrophy is present ; if dilatation, feeble and indis- 
tinct. 

Percussion. The area of dulness is increased, in the earlier stages, 
to the left and downward. After compensation is broken, dilatation 
with increased area of dulness ensues. 

Auscultation. A murmur is heard of maximum intensity at the 
second costal cartilage to the right, systolic in time, and transmitted in 
the course of the bloodvessels. (See Fig. 174.) It is usually harsh 
and loud, but may be musical. As the heart weakens, the intensity 
of the murmur lessens and its roughening disappears. It becomes soft 
and low in pitch. The second sound, if there is no regurgitation, is 
muffled or may be absent. The pulse is small and regular. The ten- 
sion is usually increased. 

Diagnosis. A systolic murmur at the aortic orifice may be due to 
aortic obstruction, atheroma or dilatation of the aorta, ulcerative aor- 



660 SPECIAL DIAGNOSIS. 

titis, or anaemia. Huchard describes a murmur in this situation, with 
vibratory thrill, due to aberrant chordae tendineae. The murmur of 
aortic stenosis is distinguished from the others by its character, by 
the presence of thrill, by the character of the pulse, and by its associa- 
tion with hypertrophy of the left ventricle. A murmur due to athe- 
roma of the aorta, particularly in the course of renal disease, is also 
associated with hypertrophy of the left ventricle. The diagnosis from 
aortic obstruction is often difficult or impossible. Slowness of the pulse 
is more characteristic of aortic obstruction. The murmur of anaemia is 
softer and low in pitch. There is no thrill, and the left ventricle is not 
hypertrophied. Anaemic murmurs may be heard elsewhere. In athe- 
roma the second sound is usually accentuated, and in anaemia also it is 
intensified. 

Mitral Incompetency or Regurgitation. The regurgitation may 
be due to disease of the valves (organic) from previous endocarditis, 
or to inability of the segments to close the orifice (incompetency), which 
has become enlarged as part of the dilatation of the cavities. The latter 
occurs in dilatation of the left ventricle. It takes place when the 
muscle is weak in fevers and in anaemia. It is thus seen that the mur- 
mur of mitral insufficiency is one of the most commonly observed of all 
valve-murmurs. Its ready production and often equally ready removal 
with treatment make it the least serious. It must not be forgotten 
that insufficiency from disease of the valves and from disease of the 
muscles must, if possible, be distinguished from each other. The 
history of the case is essential in determining the diagnosis. 

Disease at the mitral orifice producing insufficiency has more serious 
effect upon the pulmonic and arterial circulation than disease at any of 
the other orifices. These effects must be understood in order to appre- 
ciate the symptoms of mitral incompetency. They are as follows : 1. 
With each systolic contraction the blood flows back, on account of the 
insufficiency, to the auricle, where it soon meets a volume of blood 
coming from the lungs. The combined volumes of blood overdistend 
the auricle. Dilatation ensues, and because of increased work to get 
rid of the increased contents, hypertrophy follows. Dilated hypertro- 
phy of the left auricle is the first effect. 2. As a result of the above, 
a larger amount of blood is forced from the left auricle into the left 
ventricle ; dilatation and subsequent hypertrophy of this chamber also 
follow, to remove the fluid. 3. On account of the overdistended auri- 
cle the pulmonary veins are not fully emptied during the diastole of 
that chamber. The veins are therefore engorged and interfere with 
the flow of blood through the pulmonary circuit. In consequence of 
the impeded flow of blood the vessels in the pulmonary circuit are 
dilated and overdistended. The right ventricle is compelled to act 
more vigorously, and even then cannot empty itself freely. Dila- 
tation and hypertrophy of the right ventricle ensue. 4. This causes 
obstruction of the flow of blood from the right auricle to the right 
ventricle ; dilatation and hypertrophy of its chambers follow. If 
perfect compensation ensues through hypertrophy of both ventricles, 
engorgement in the lungs may not be observed. Moreover, the left 
ventricle is allowed to send out sufficient blood to supply the wants of 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 661 

the system. This compensation may continue for years. If it fails, 
either from increase in the valve-lesion, or valvular incompetency, or 
from weakening of the muscle, a normal amount of blood is not dis- 
tributed throughout the aortic area, but is thrown back upon (1) the 
left auricle ; (2) the pulmonary circulation ; (3) the right heart ; and, 
finally, the systemic veins. For a time the pulmonary circuit will 
alone be engorged, subsequently the systemic veins become congested 
because of dilatation of the right auricle and incompetency of the tri- 
cuspid valves. We then have the secondary effects of stasis upon the 
various organs of the body, with cyanotic induration and the develop- 
ment of dropsies. Mitral incompetency without disease of the valves is 
of frequent occurrence in emphysema of the lungs and in Bright's dis- 
ease, and is a condition which always attends hypertrophy and dilata- 
tion, or may take place from various causes. (See Hypertrophy and 
Dilatation.) 

Symptoms. As to the general symptoms : In a large number of 
cases perfect compensation may continue for a long time. No subjec- 
tive symptoms arise nor are there symptoms due to dilatation. If 
compensation is not perfectly effected from the first, or is broken sud- 
denly or gradually, the symptoms of dilatation arise. 

In patients in whom compensation remains only fairly good we have 
the characteristic appearances of heart disease. It is to this class of 
patients that the general descriptions of heart disease apply. The face is 
pale and pinched, the lips and ears dusky, the capillaries of the cheeks 
enlarged, the finger-nails clubbed, particularly in children ; shortness of 
breath on exertion may be the only symptom complained of, and this 
may exist for years. The patients are, however, liable to attacks of 
bronchitis and of pulmonary hemorrhage. Palpitation may occur in 
this as in other forms of heart disease, and from the same cause. 

When the compensation is broken, symptoms referable to the heart 
and to engorgement of systemic and pulmonary veins occur. Of the 
former palpitation with a sense of oppression is the most common ; 
pain is rare. 

Venous engorgement leads to congestions, cyanosis, and dropsies. 
We now have the symptoms of dilated right heart superadded. The 
lungs are the first to be congested. Dyspnoea becomes constant and 
is aggravated by exertion. Cough is present, excited by exertion or 
speaking. With the cough there is bloody expectoration. Cyanosis 
occurs. Congestion of other organs follows. The liver is enlarged ; 
obstruction in the portal area is prominent ; chronic gastritis or gastro- 
intestinal catarrh ensues. The spleen is enlarged ; ascites develops, 
and hemorrhoids and congestion in the rest of the portal area are seen. 
The kidneys are congested ; the urine is scanty, albuminous, and con- 
tains casts and blood-corpuscles. At the same time that the internal 
viscera are congested dropsies take place, beginning in the feet and 
extending to the rest of the body. Dropsy may have been present in 
the feet before symptoms of portal congestion ensued. 

The patient may be relieved and compensation continue for a long 
time. Frequent attacks of dilatation of this character may take place, 
their recurrence being due to lack of care in hygienic matters, or 



662 SPECIAL DIAGNOSIS. 

failure in health from other causes. Finally, however, the compen- 
sation cannot be restored ; the stases persist ; the dropsies become 
more marked, and the symptoms of cyanotic induration and secondary 
scleroses of the internal organs follow. It must not be forgotten that 
this is the chief form of organic heart disease seen in children. 

Physical Signs. (Plate XXX., Fig. 1.) On inspection the pre- 
cordial area appears prominent ; the apex-beat is displaced to the left 
and downward, rarely below the sixth interspace. It may extend to 
the anterior axillary line. The cervical veins pulsate and are dis- 
tended. The area of impulse is increased. 

Palpation. The character of the impulse depends upon the stage 
of the disease at which the case is examined. At the time of full com- 
pensation it is strong and even. When this is broken, it is feeble and 
diffuse. A thrill is extremely rare. 

The Bloodvessels. The amount of blood in the arteries is dimin- 
ished. There is notable absence of visible pulsation in the arteries. 
The pulse at first is full and regular. It is notably small in volume 
and soft. As soon as failure of compensation takes place the pulse 
becomes irregular. The irregularity may be that of time as well as of 
volume. 

Percussion. The area of dulness is increased to the left. The trans- 
verse diameter of the heart is much increased because of dilatation 
of both chambers. The area extends beyond the right margin of the 
sternum to the extent of an inch or more and to the left as far as the 
mid-clavicular line, sometimes to the anterior axillary line. The 
cardio-hepatic triangle is preserved. 

Auscultation At the apex, the mitral area, a murmur is heard. 
The point of maximum intensity is in this region. It is systolic in 
time ; it may replace the first sound entirely. It may be soft and low 
in pitch, or rough, high in pitch, even musical in character. It is 
transmitted to the axilla and the angle of the scapula. (See Fig. 171.) 
In some instances it may be heard loudest along the left border of the 
sternum. The pulmonary second sound is accentuated ; the accentu- 
ation is loudest in the pulmonary area at the second left interspace. 
It may be very loud over the right ventricle, between the paraster- 
nal line and tlie left edge of the sternum. The murmur of mitral 
insufficiency is modified by the position of the patient and intensified 
after exertion. It may be present when the patient is lying down, 
and disappear in an erect posture. It may disappear when the patient 
is quiet and return after exertion. Other murmurs are sometimes heard : 

1. A presystolic murmur, soft or rumbling. 2. When dilatation 
ensues a low-pitched systolic murmur is heard at the ensiform carti- 
lage and at the lower left border of the sternum. It is due to tricus- 
pid regurgitation. 

Of special diagnostic significance are : the position of the murmur 
and the direction of its transmission ; accentuation of the pulmonary 
second sound ; enlargement of the transverse diameter of the heart, 
due to dilatation of both ventricles. 

DIAGNOSIS. This is usually easy if the physical signs are sought 
for. Very often examination of the heart is neglected, and the patient 



PLATE XXX, 







Mf 



Mitral Regurgitation. 
FIO. 2. 



-. 




- thrill 



Xm 



^ 



M^ 



Mitral Stenosis. 






DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 663 

is treated for the symptoms that arise from congestion of the viscera. 
We have often seen chronic gastritis or gastro-intestinal catarrh, clue 
to mitral insufficiency, not relieved because the primary lesions had 
not been ascertained. In the same way cardiac cough or dyspnoea may 
be overlooked. It is important in the diagnosis to determine, if possi- 
ble, the nature of the insufficiency, whether it is due to disease or 
incompetency of the valves. As previously mentioned, the history is 
possibly the only means by which a diagnosis can be made. If a 
mitral murmur ensues in old people, in whom there has been physical 
cause for the development of dilatation and hypertrophy, as in emphy- 
sema or arterio-sclerosis, it is usually due to relative incompetency of 
the valve. It must not be forgotten that the mitral area is the seat of 
a number of murmurs due to various causes. (See Auscultation.) 

Mitral Stenosis. Obstruction to the flow of blood from the auricle 
to the ventricle is due to valvulitis, or endocarditis, and particularly 
the endocarditis of early life. It is of much more frequent occurrence 
in women than aortic disease. It is much more often seen in young 
adults and children, because its etiological factors, rheumatism and 
chorea, are then more prevalent. 

On account of the obstruction at the orifice changes ensue in the 
auricle. These changes depend in a measure upon the nature of the 
lesion. In the so-called buttonhole contraction they are very marked. 
The orifice may be so obliterated in rare cases as to admit only a small 
probe. Dilatation and hypertrophy of the left auricle ensue if the 
valve-changes take place gradually. The walls of the auricle are 
thickened to three or four times their natural size. On account of the 
dilatation of this auricle the outflow from the pulmonary veins is im- 
peded, which in turn obstructs the circulation of blood through the 
lungs. As a consequence, dilatation and hypertrophy of the right ven- 
tricle occur. As a result of this we have, later on, the occurrence of 
relative incompetency at the tricuspid orifice, with engorgement of the 
systemic veins. The left ventricle does not take part in any changes. 
It retains its normal size, but it may look small in comparison with 
the right ventricle. 

Symptoms. If hypertrophy of the right ventricle ensues, the com- 
pensation may be sufficient to prevent the occurrence of symptoms for 
many years. The disease may exist for a number of years without 
discomfort to the patient. Because of its rheumatic origin a fresh 
endocarditis may develop, particularly as most of the subjects are 
young. The old valve lesion invites infection, and so a recurrent form 
of endocarditis is induced. If fresh endocarditis occurs, embolic symp- 
toms are likely to follow. Embolism takes place particularly in the 
brain, causing hemiplegia or aphasia. When failure of compensation 
takes place the symptoms described in mitral incompetency arise. 
They are the symptoms of dilatation of the heart, and may recur 
frequently during a long period of years. 

Dropsy, however, is not so common as in mitral regurgitation. 
Visceral stases are common when compensation fails, and in many 
cases we find enlargement of the liver continuing for a long period. 
Ascites may in rare cases be the only manifestation of mitral obstruction. 



664 SPECIAL DIAGNOSIS. 

Physical Signs. (Plate XXX., Fig. 2.) The physical signs of 
mitral obstruction are more striking and more diagnostic of the lesion 
than the physical signs of any other form of organic heart disease. 

Inspection. As the disease develops in children with soft ribs the 
local deformities are very marked. For the same reason precordial 
bulging is more prominent. Because the right ventricle is hypertro- 
phied, the sternum and the fourth, fifth, and sixth costal cartilages pro- 
trude. The apex impulse is not usually displaced, certainly not beyond 
the mid-clavicular line. The impulse is not marked at the apex. In 
the third and fourth interspaces a visible impulse is seen along the 
margin of the sternum. After dilatation the extent of impulse dimin- 
ishes and the veins of the neck become engorged, the blood regurgi- 
tating into them during the systole. 

Palpation. In the large majority of cases a distinct fremitus or 
thrill is felt — more marked in the fourth or fifth interspace, inside of 
the nipple. It is usually localized to a small area, is increased during 
expiration, and is of a twisting, grating, or grinding character. It is 
made up of a series of small shocks increasing in intensity, culminating 
in a sudden, sharp shock, which occurs at the time of the impulse. 
The thrill and systolic shock are pathognomonic, and may be present 
when other signs, as the murmur, are absent or indistinct. The car- 
diac impulse is felt strongest at the lower margin of the sternum and 
in the third and fourth interspaces, in some cases even in the second. 
It is due to an enlarged and dilated right ventricle. 

The Pulse. With perfect compensation the pulse is slow, regular, 
and firm, although small. If the orifice is much narrowed, small, 
weak, and irregular in force and rhythm. When compensation fails 
and the right heart is dilated the pulse becomes rapid, quick, weak, 
small in size, and irregular in force and rhythm. The dilatation 
may be so great that the right auricle and overdistended veins may 
press upon the aorta or the innominate and subclavian arteries. The 
pulse on that side will be lessened in volume. 1 

Percussion. The area of cardiac dulness is increased upward and 
to the right and left of the margin of the sternum. Sometimes it ex- 
tends upward as high as the second rib ; this increase is quite charac- 
teristic. 

Auscultation. At the apex, or just inside of the position of the 
apex-beat, a murmur is beard, its point of maximum intensity dis- 
tinctly localized to this spot. It is usually not transmitted. (See Fig. 
172.) It is of a churning and grinding character, or vibratory and 
purring. It is usually high in pitch and rough. It occurs synchro- 
nously with the thrill, and terminates with a loud shock that is heard 
simultaneously with the first sound. It is, therefore, presystolic in 
time. As has been said of the thrill, so it may be said of this murmur, 
that it is the only murmur that is pathognomonic of a special lesion. 
It indicates narrowing of the mitral orifice. The only exception, in 
which the lesion is absent, although the murmur is present, is found 
in the class of cases described by Flint, referred to in the section on 

1 Popoff : British Medical Journal, 1893. 



PLATE XXX 



FIG. 1. 



Sysm sftuts 





\>u» 



Tricuspid Regurgitation. 

FIG. 2. 




THriflf?)-+ 



Tricuspid Stenosis. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 665 

aortic regurgitation. The first sound is loud, clear, and abrupt ; it 
may be thumping. 

the presystolic murmur may occupy the entire period of the dias- 
tole, but in the large majority of cases it occurs in the latter half only, 
during which the auricular systole occurs. In some instances it is 
heard in the middle of the diastole. 

Associate Murmurs. 1. At the same time a systolic murmur may 
be heard at the apex, soft and low in pitch. It may be transmitted 
into the axilla. It is usually due to associate mitral regurgitation. 2. 
At the lower portion of the sternum a systolic murmur may be heard, 
due to dilatation and incompetency at the tricuspid orifice. Murmurs 
in the aortic region are not usually heard. 

The second sound at the pulmonary orifice is usually accentuated. It 
is heard in the second and third interspaces along the left edge of the 
sternum ; it may be heard at the apex. Reduplication of the first 
sound is often observed. Reduplication of the second sound is very 
common. After compensation is broken other murmurs may be heard, 
and the presystolic murmur changes in character. It may disappear 
entirely and be replaced by a sharp first sound. The short, high- 
pitched systolic shock may continue, although the murmur disappears. 
It disappears probably because the left auricle has become weakened. 
The tricuspid murmur continues during this period. 

The points of distinction of mitral obstruction are (1) the position of 
the murmur ; (2) its restricted area ; (3) its peculiar character ; (4) the 
systolic shock which takes the place of the first sound ; (5) the thrill ; (6) 
the impulse and increased area of dulness upward ; (7) accentuated 
pulmonary second sound ; (8) reduplication ; (9) the absence of the pulse 
of aortic regurgitation and of hypertrophy of the left ventricle. 

Presystolic Murmur not due to Valvulitis. A presystolic 
murmur without mitral obstruction may occur in aortic regurgitation 
and in adherent pericardium. 

Tricuspid Regurgitation or Incompetency. Structural disease at 
the tricuspid orifice is of comparatively rare occurrence. Insufficiency 
is more frequent, and is due to dilatation, with relative insufficiency of 
the valve-orifice. It occurs secondarily to obstructive lung diseases, 
as emphysema and cirrhosis, and is secondary to regurgitation at the 
mitral orifice, which leads to stasis in the lungs. 

Symptoms. The symptoms were detailed in speaking of the mitral 
valve affections. They are those of obstruction in the pulmonary cir- 
culation and engorgement of the systemic veins. 

Physical Signs. (Plate XXXI., Fig. 1.) Inspection. The physical 
signs of dilatation of the right heart are seen. An impulse in the epi- 
gastrium is noted. This is seen especially between the xiphoid cartilage 
and the left margin of the ribs. Pulsation to the right of the sternum 
and in the second and third intercostal spaces may also be observed. 
The veins of the neck are also seen to pulsate. In addition to the wavy 
pulsation, regurgitation of the blood into the right auricle causes trans- 
mission of the pulse-wave into the veins. The pulsation is systolic in 
time. It is more marked in the right jugular than in the left, and in 
the external than in the internal veins. With the pulsation, regurgi- 



QQQ SPECIAL DIAGNOSIS. 

tation is readily observed by emptying the external vein. Place the 
finger firmly on the vein jnst above the clavicle, move it along the 
course of the vein in the direction of the inferior maxillary bone. The 
vein is thus emptied of blood, and with each systole of the heart it will 
be seen to fill np from below in rhythmical pulsation. The veins are 
increased in size. This is more noticeable during the act of coughing 
or when the patient holds his breath in full inspiration. In rare in- 
stances the pulsation is transmitted to the subclavian and axillary veins. 

Palpation. By palpation the above conditions are also determined. 
The impulse over the lower sternum and in the epigastrium is noted 
to be forcible. 

The regurgitant pulsation is transmitted to the descending vena cava 
as well as to the ascending. The hepatic veins also distend during 
the systole. So-called pulsation of the liver is produced. With one 
hand on the fifth and sixth costal cartilages and the other over the 
liver in the axillary region, rhythmical expansile pulsation may be 
recognized. It is not of common occurrence, but is absolutely diag- 
nostic of regurgitation at the tricuspid orifice. 

Percussion. The area of cardiac dulness is increased transversely 
and upward, as described in mitral stenosis. It extends often far be- 
yond the right edge of the sternum. 

Auscultation. At the xiphoid cartilage, the lower end of the ster- 
num or the head of the fourth rib, a murmur is heard. It is sys- 
tolic in time, usually low in pitch, and is heard loud to the left of the 
sternum, within an inch of the apex, and to the right of the sternum 
and the outer limits of percussion-dulness. (See Fig. 173.) It is not 
further transmitted. Other murmurs are heard, due to the primary 
organic disease. If the heart is weak, the lesion may not be produc- 
tive of a murmur. The pulmonary second sound is accentuated. 

Tricuspid Stenosis. Stenosis at this valve-orifice is generally of 
congenital origin. In rare instances it may be secondary to lesions in 
the left heart. It is accompanied by dilatation of the right auricle. 

The physical signs (Plate XXXI., Pig. 2) are the same as in stenosis 
at the mitral orifice, except for the alteration in their position. In 
some instances a presystolic thrill has been observed, and with it a 
presystolic murmur at the lower end of the sternum or toward the right 
of it. The area of dulness is increased as in right-sided dilatation. 
Cyanosis is a prominent symptom and may be intense. 

Disease of the Pulmonary Valve. Diseases of the pulmonary 
valve are extremely rare and are almost always congenital. 

Pulmonary Insufficiency. (Plate XXXIL, Fig. 1.) The physical 
signs arc due to regurgitation into the right ventricle. The maximum 
intensity of the murmur is in the second pulmonary interspace, and it 
is transmitted down the sternum. It cannot be distinguished from 
aortic regurgitation, except by the pulse. 

Pulmonary Stenosis. (Plate XXXIL, Fig. 2.) In stenosis of the 
pulmonary valve a systolic murmur and thrill are detected to the left of 
the sternum in the second interspace. The murmur is not transmitted 
to the vessels of the neck. The pulmonary second sound is weak. 
The effect on the heart is the production of right-sided hypertrophy. 



PLATE XXXII 



FIG. 1. 



''*"■ '-rr-.. 



■^ 






■'Uiir- 



^ 




Pulmonary Insufficiency. 



FIG. 2. 



\ 



X. 




\ 



Pulmonary Stenosis. 



PLATE XXXIII. 

FIG. 1. 




V 






Combined Mitral and Aortic Insufficiency and Stenosis. 



FIG. 2. 



StfsM. kills. 




-^m.. 



Mf 



Combined Mitral and Tricuspid Insufficien 



cy. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 667 

Combined Valvular Lesions. (Plate XXXIII.) It must not be 
forgotten that there may be disease causing both obstruction and re- 
gurgitation at the same time and at the same orifice, or that two or 
more valves may be the seat of disease in the same individual. It is 
not impossible, for instance, to have aortic obstruction and regurgita- 
tion, mitral obstruction and regurgitation, and tricuspid regurgitation. 
Aortic obstruction or insufficiency is frequently combined with mitral 
insufficiency. Aortic and mitral insufficiency occur together most fre- 
quently in children ; aortic obstruction and mitral obstruction in adults. 

When more than one valve is diseased the site of the various lesions 
is based upon the time, the position of maximum intensity, and the 
direction of transmission of the murmurs. Students often experience 
difficulty here. A systolic murmur may be heard in the aortic area and 
in the mitral area at the same time. If it is observed that each pro- 
gressively weakens as the stethoscope is moved toward the middle of 
the precordial area, it may be inferred that the murmur, systolic in 
time, is due to two lesions. As previously intimated, the direction of 
the transmission of the murmur further aids in the diagnosis. 

Enlargement of the Heart. 

Enlargement of the heart is due to hypertrophy or to dilatation. In 
hypertrophy there is increased thickness of the muscular walls. This 
may be general or limited to the walls of one chamber. Hypertrophy 
is further divided into simple hypertrophy, in which the cavity or 
cavities are of normal size, and eccentric hypertrophy, in which, with 
increase in the wall, there is enlargement of the cavities. This is 
hypertrophy with dilatation. The left ventricle is most frequently the 
seat of hypertrophy when one chamber is involved. The cause of 
hypertrophy is obstruction to the flow of blood ; increased work is fol- 
lowed by increased size of the muscle. General hypertrophy or hyper- 
trophy of the left ventricle occurs from diseases of the heart itself, or 
from affections of the bloodvessels. 

A. Diseases of the heart. 1. Disease of the aortic valves. Hyper- 
trophy of the left ventricle always follows. 2. Mitral regurgitation. 
3. Pericardial adhesions. 4. Myocarditis of the fibrous variety. 5. 
Neuroses with overaction and frequent palpitation, as in exophthal- 
mic goitre and from the effects of tea, tobacco, and alcohol. In peri- 
cardial adhesions and myocarditis hypertrophy arises because of the 
inability of the heart to do the work expected of it. There is no ob- 
struction in the course of the vessels or at the orifices. The struggle 
to keep up causes the hypertrophy. In neuroses there is absence of 
obstruction, but the rapid action causes hypertrophy. 

B. Affections of the bloodvessels which cause hypertrophy are : 1. 
General arterial sclerosis. 2. Increased arterial tension due to con- 
traction of the peripheral arteries, as in Bright' s disease, and in tox- 
emias from lead, the poison of gout and of syphilis. 3. Increased 
blood-pressure from prolonged muscular exertion. 4. Narrowing of 
the aorta from external pressure and from congenital stenosis or the 
development of an aneurism. 



6(38 SPECIAL DIAGNOSIS. 

Hypertrophy of the Bight Ventricle. Obstruction to the flow of blood 
in the pulmonary area is the usual cause of hypertrophy of the right 
ventricle. This obstruction occurs in lesions of the mitral valve, caus- 
ing pulmonary stasis ; and disease of the lungs, causing compression 
of the bloodvessels, as in emphysema or cirrhosis. It occurs if there 
is disease of the right heart with obstruction of the valves. Thus in 
obstruction at the pulmonary orifice the right ventricle undergoes 
secondary hypertrophy. 

Hypertrophy of the Auricles. Simple hypertrophy of the left auri- 
cle with dilatation develops in mitral stenosis. Hypertrophy of the 
right auricle occurs in tricuspid obstruction and in right-sided dilata- 
tion with tricuspid regurgitation. 

Symptoms. The symptoms of hypertrophy of the heart are general 
and local. The former are not common. They are due to increased 
tension in the cerebral vessels because of increased force of the heart, 
usually causing congestive headaches, noises in the ears, flashes of light, 
and flushing of the face. 

General symptoms arise in hypertrophy of the left ventricle because 
the increased force causes reactive spasm of peripheral vessels, and 
hence increased tension in the vascular system. In Bright' s disease, 
for instance, or heightened arterial tension from other causes, endarter- 
itis develops in the large vessels, on account of the strain put upon them. 
This is seen particularly in the aorta and its divisions. Whether 
atheroma is primary or secondary, its presence, with hypertrophy of 
the left ventricle, indicates that rupture of the vessels somewhere in the 
periphery may take place. This occurs most frequently hi the brain, 
causing apoplexy. 

Locally, the patient complains of fulness and discomfort, particularly 
marked when lying down on the left side. In the hypertrophy that 
accompanies the tobacco-heart, or the irritable heart of soldiers, there 
may be some pain. On the other hand, the organ may be enormously 
enlarged without the patient complaining of discomfort about the heart. 
Palpitation is not of common occurrence except in neurasthenic subjects. 

Physical Signs. The hypertrophy causes precordial bulging, if 
it has developed early in life, when the ribs are soft. The intercostal 
spaces are widened and the area of impulse is much increased. The 
normal impulse is changed in position. It is downward and to the 
left, often extending as far as the axilla in hypertrophy of the left 
ventricle. 

Palpation. The impulse is forcible and heaving. The head is 
visibly raised with each systole when placed upon the chest for auscul- 
tation. The impulse is slow. This slow, heaving impulse distin- 
guishes it from the forcible impulse of dilated hypertrophy, which is 
sudden and abrupt. Inspection is confirmed as to the position of the 
apex. In moderate hypertrophy the apex extends to the sixth inter- 
space in the mid-clavicular line. In large-sized hypertrophy it may 
extend to the seventh interspace. The heart may be apparently 
hypertrophied in fibrous and fatty myocarditis. The impulse may be 
absent in emphysema, in fatty overgrowth of the heart, and in persons 
with thick chest-walls. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 669 

The Pulse. The frequency of the pulse is not affected. It is full, 
regular, and strong. The tension is increased. In dilated hyper- 
trophy the pulse is full but soft, and more rapid than in simple hyper- 
trophy. When failure of the heart takes place the pulse increases in 
frequency and becomes intermittent and irregular. When valve-lesions 
are present the pulse is modified accordingly. 

Percussion. The area of dulness is increased both upward and 
transversely. It may begin as high as the second interspace and ex- 
tend two inches beyond the left mid-clavicular line, and an inch beyond 
the right edge of the sternum transversely. In simple hypertrophy 
the area is ovoid. 

Auscultation. When the valves are healthy, prolongations of the first 
sounds occur. They are also at times duller than in health. The dull, 
prolonged first sounds distinguish hypertrophy from dilatation, for in 
the latter they are clear and sharp. The second sounds are clear and 
loud. The degree of accentuation depends upon the state of the per- 
ipheral arteries. If there is heightened tension, the second sound may 
be reduplicated. If valvular disease is present, the sounds are modified. 

Hypertrophy of the Right Ventricle. Increased pulmonary 
tension from resistance in the pulmonary circulation may always be 
looked for. If there is complete compensation, no symptoms are ob- 
served, or only those of dyspnoea on extra exertion. Hypertrophy of 
this ventricle persists for a long period of time without the grave local 
changes in the heart, or secondary changes in the peripheral vessels, 
which occur in left ventricle hypertrophy. In dilated hypertrophy, 
when the dilatation is in excess, tricuspid regurgitation takes place, 
with the development of venous stases. Induration of the lungs may 
succeed the persistent engorgement of the capillaries. Pulmonary con- 
gestions and apoplexy may also occur. 

Physical Signs. The physical signs of hypertrophy of the right 
ventricle have been partially referred to under the various valve affec- 
tions. There is bulging of the lower part of the sternum and carti- 
lages. The epigastric impulse in the angle between the ensiform carti- 
lage and the ribs has been referred to. The impulse may be in the 
sixth interspace. It is diffuse ; it may extend upward as in mitral 
stenosis. Cardiac dulness is increased toward the right an inch or 
more beyond the border of the sternum. The heart-sounds are not 
much changed unless there is dilatation. The tricuspid sound is clear 
and sharp when this occurs. The pulmonary second sound is accentu- 
ated, and reduplication may take place. The radial pulse is small. 
If there is tricuspid regurgitation, the physical signs that attend it 
are present. 

Hypertrophy of the Left Auricle. This is present in mitral 
stenosis, but cannot be determined by physical signs, save possibly by 
greater increase of dulness to the left of the sternum in the second 
and third interspaces. Barr states that dulness above the " supraster- 
nal mammillary line " toward the left clavicle indicates enlargement of 
the left auricle, as in mitral stenosis. The line above mentioned is 
drawn from the middle of the suprasternal notch to the normal site of 
the left nipple on the fourth rib. 



670 SPECIAL DIAGNOSIS. 

Hypertrophy of the right auricle with dilatation occurs 
under the same circumstances as hypertrophy of the ventricle. It 
usually dilates more than the left auricle in left ventricle hypertrophy. 
There is increased area of dulness in the third and fourth right inter- 
spaces ; abnormal pulsation is sometimes observed in this situation 
before the systole, with the signs of tricuspid regurgitation. 

Diagnosis. The forcible impulse in nervous palpitation of the 
heart must not be confounded with true hypertrophy, although it 
must not be forgotten that hypertrophy frequently follows neurotic 
palpitation, as in the smoker's heart, or in exophthalmic goitre. 
The enlargement must not be confounded with enlargement of the 
area of cardiac dulness in the precordial region from other causes, 
such as pericardial effusion ; aneurism and mediastinal tumor, push- 
ing the heart against the chest-wall ; disease of the lungs, on ac- 
count of which they are withdrawn from the surface of the heart, as 
in phthisis or chronic pleurisy ; and displacement of the heart from 
pressure, as in effusion on the left side of the chest, or in disease below 
the diaphragm. The cause of hypertrophy should be ascertained, for 
it is a valuable aid in diagnosis. It must not be forgotten that emphy- 
sema of the lung may mask a considerable hypertrophy of the heart 
by causing diminution of the area of dulness. 

Dilatation of the Heart. Enlargement due to dilatation of the 
heart is common. The condition usually succeeds hypertrophy. 
Thickening of the muscles attends dilatation of the cavities, as in 
dilated or eccentric hypertrophy. The dilatation occurs because of in- 
creased pressure within the cavities or because of weakening of the 
heart- walls, the pressure within being normal. 

1 . Increased pressure within the walls is due to an increased amount 
of blood within the chamber from regurgitation, or from an obstacle 
to the outward flow of blood. Simple hypertrophy occurs first in 
many cases ; in others, hypertrophy with dilatation ; in not a few, 
dilatation takes place at once. In dilatation the chamber does not 
empty itself during the systole. It is seen physiologically after the 
exertion of ascending a great height. It may remain within the 
bounds of physiological action. Temporarily, as any one can show 
by running violently, the dilatation is attended by increased epi- 
gastric pulsation and increased cardiac dulness. The tricuspid valves 
temporarily become incompetent, owing to their safety-valve action. 
The latter may continue after the acute strain, the heart always show- 
ing symptoms of the condition, or it may disappear entirely. An 
excessive dilatation results in heart-strain, with cardiac distress and 
dyspnoea, symptoms due to overdistention and paralysis of the heart. 
(See Symptoms.) Dilatation occurs in all forms of heart-lesions pre- 
viously described. The most typical is seen in aortic regurgitation, 
when the left ventricle becomes the seat of dilatation, and in mitral 
regurgitation when the left auricle becomes the seat of dilatation. 

2. Disease of the heart-walls, lessening the resisting power, the nor- 
mal pressure within the cavities being maintained, invites dilatation. 
In myocarditis, in infections, acute dilatation may ensue. It occurs in 
scarlatinal dropsy, typhoid fever, rheumatic fever, and erysipelas. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 671 

The heart-muscle changes in acute endocarditis and pericarditis, on 
account of which dilatation may ensue. In ansemia and chlorosis the 
same process may take place. In chronic myocarditis dilatation takes 
place at the apex. When pericardial adhesions are present the fibrous 
overgrowth invades the interstices of the myocardium, thereby weaken- 
ing the heart-muscle. Dilatation may follow. 

Symptoms. The symptoms of dilatation are the reverse of those 
of hypertrophy. When the latter fails the blood is not expelled from 
the chambers in systole, so that the cavity is overdistended with 
blood that accumulates in the diastole. Weakening of the muscles 
also favors the development of dilatation. As soon as dilatation be- 
comes permanent, incompetency of the valves takes place. In obstruc- 
tive heart disease the left side is first affected. It may be compen- 
sated for by hypertrophy of the right side. When this fails venous 
engorgement and dropsy ensue. The symptoms have been described 
under chronic valvular disease. In acute dilatation there is a sudden 
occurrence of dyspnoea. Pain, or at least precordial oppression, may 
be complained of. The heart's action increases in frequency. The 
pulse is rapid, feeble, irregular, and may scarcely be felt at the wrist. 

Physical Signs* Inspection. The apex is displaced to the left, 
even as far as the axillary line, but rarely downward, unless hypertro- 
phy precedes the dilatation. The impulse is diffused and undulatory 
in appearance. The apex-beat may be defined with extreme difficulty. 
It may be visible when the patient leans forward, yet not felt. 

With the diffused area of impulse a quick apex-beat may be felt — 
much weakened, however. When the right ventricle is dilated, the 
impulse is seen and felt to the right or left of the xiphoid cartilage, 
and there is a wavy pulsation along the left edge of the sternum 
in the fourth, fifth, and sixth interspaces. If the dilatation is extreme, 
involving the right auricle, a pulsation at the third right interspace 
close to the sternum may be felt. Tricuspid regurgitation is then 
present. 

The area of dulness is increased in the same directions as in hyper- 
trophy, if the two coexist. In general, it may be said the increase 
extends outward to the right or left, the direction corresponding to 
the ventricle affected. It is increased upward along the left edge of 
the sternum in left auricle dilatation. (See Mitral Valvulitis.) When 
the whole heart is dilated the increase of dulness is in a transverse 
direction on both sides. The apex is rounded or square, not pointed, 
as in hypertrophy ; indeed, it retains the oval shape of the dulness 
of a normal heart. As dilatation occurs so frequently in emphysema 
of the lungs, the modification of the percussion-sound must be re- 
membered. 

Auscultation. The systolic sounds are short and sharp. They are 
high-pitched and resemble the diastolic. The latter may become 
enfeebled when the dilatation becomes excessive. The right and left 
first sounds may differ somewhat in intensity, and reduplication may 
occur. The sounds may be obscured by murmurs. The murmurs 
are due to previous valve disease or to incompetency, on account of 
dilatation. The action of the heart is irregular and intermittent. The 



672 SPECIAL DIAGNOSIS. 

pulse is correspondingly small. In dilatation the alteration of the 
rhythm is extreme. There may be embryocardia or foetal-heart rhythm, 
in which the first and second sounds are alike, and the long pause is 
shortened. More frequently we have galloping rhythm of the heart. 
It must not be forgotten that, as dilatation ensues, murmurs of various 
valve-lesions may disappear, particularly the murmur of mitral steno- 
sis. On the other hand, in the earlier stages particularly, murmurs 
develop, on account of incompetency at the auriculo- ventricular orifices, 
in addition to the primary organic murmur. These murmurs in turn 
may disappear, if the dilatation is controlled by careful treatment. 

Diseases of the Arteries. 

Arterial Sclerosis or Arterio-capillary Fibrosis. This 
occurs as the result of wear and tear of life and as the accompaniment 
of age. The time of its onset depends upon the quality of the arterial 
tissue which the individual inherited, and upon the amount of wear 
and tear. It may occur early in life, and entire families may show 
this tendency. Very frequently the sclerosis develops from intoxica- 
tions of the system, on account of which persistent spasm of the small 
vessels is set up — for blood of an impaired quality is passed with greater 
difficulty through the capillaries, as was taught by Bright. The blood- 
tension is raised thereby. The poison of alcohol, of lead, of gout, and 
of syphilis leads to this condition. The poison of syphilis and of gout 
may set up directly an inflammation and degeneration of the arteries. 
In renal disease arterial sclerosis is of common occurrence. The rela- 
tion to the renal lesion differs. It may be primary or secondary. 
When primary, the morbid cause operates upon the kidneys as well as 
the arteries. When secondary a morbid poison is retained within the 
system by the diseased kidneys, the action of which is such as to cause 
peripheral spasm and heightened tension. 

Overfilling of the bloodvessels from excessive eating and drinking 
is thought by some to cause arterial sclerosis through constant overdis- 
tention of the vessels. In overwork of the vessels and excessive strain 
there is either heightened tension or increased peripheral resistance, 
the effect upon the bloodvessels being the same in either case. The 
result of the above causes is thickening of the intima, followed by 
changes in the media and adventitia, terminating in endarteritis de- 
formans of the large arteries. 

Symptoms. The symptoms vary. They may be general or local. 
The disease may be present and the patients die from other causes. 
Local symptoms are due to rupture of the vessels, as in apoplexy from 
cerebral hemorrhage, or to their obstruction, as the coronary artery, or 
to rupture of an aneurism. 

Physical Signs. Arterio-sclerosis is recognized by inspection, 
palpation, and auscultation of the bloodvessels, and by observation 
of the condition of the heart. The superficial bloodvessels are elon- 
gated and tortuous, and pulsate visibly. On palpation the artery feels 
very hard to the touch ; it resists compression ; it is corded or rounded 
underneath the finger, and readily rolled about. The pulse shows at 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 673 

once high tension ; the wave is slow in ascent, continues long under- 
neath the finger,- and subsides slowly. If in the interval of the beats 
the vessel remains full, the pulse, as previously noted, is obliterated 
with difficulty. Sphygmographic tracings are characteristic. (See 
Pulse.) If, after pressure on the radial artery, it can still be felt be- 
yond the point of compression, its walls are sclerosed ; whereas, if 
after such compression the artery is obliterated beyond the point of 
compression, the hardness and firmness of the pulse previously ob- 
served are due to vascular tension and not to thickened walls. The 
two conditions should be distinguished. Hypertrophy of the heart 
occurs early in the course of the sclerosis, on account of peripheral 
resistance. The hypertrophy involves the left ventricle, and is not 
attended by dilatation. The apex-beat is out beyond the mid-clavicu- 
lar line ; the impulse is heaving and forcible. The second sound at 
the aortic cartilage is characteristic. It is clear and ringing ; it is heard 
in the course of the bloodvessels, and is most distinct at or just beyond 
the apex. Right-sided hypertrophy and dilatation are not generally 
present. Auscultation of the larger arteries, as the carotids, the abdom- 
inal aorta, and femorals, shows a systolic murmur usually rough and 
high in pitch. All the above-mentioned conditions may be present, 
and yet the patient remain in good health. The hypertrophy appar- 
ently compensates for the arterial occlusion. There may be no renal 
disease, or moderate renal cirrhosis may be present, indicated by tran- 
sient albuminuria, polyuria, and hyaline tube-casts. The subsequent 
symptoms are due largely to closure of one or more vessels in the 
peripheral circulation, to the development of an aneurism or dilatation 
of the aorta, to failing hypertrophy of the heart, or to the development 
of renal cirrhosis. 

The blocking of peripheral arteries is due to embolism or throm- 
bosis, more frequently the latter, and to rupture of peripheral vessels, 
or, in all probability, miliary aneurisms. When occlusion of the 
vessels takes place in arteries which supply the extremities gangrene 
may occur. Sometimes the occlusion is due to simple narrowing of 
the vessels alone. Gangrene of the feet is frequently seen secondary 
to bad arteries. If the occlusion takes place in the vessels of the 
brain, various secondary lesions are produced. In more or less gen- 
eral occlusion from sclerosis of the smaller arteries acute and chronic 
softening occur. Hemiplegia, monoplegia, or aphasia may occur tem- 
porarily, if relieved by collateral circulation, or permanently, from 
embolism, thrombosis, or rupture of the vessels. Hence, apoplexy is 
almost always due to primary disease of the arteries, upon which, in 
the large majority of cases, miliary aneurisms have existed. If the 
coronary arteries are blocked, thrombosis with sudden death takes 
place, or chronic myocarditis may develop, with subsequent aneurism 
and rupture. Angina pectoris, with or without thrombosis of the 
coronary artery, is always associated with arterial sclerosis. 

Failure of the hypertrophied heart leads to dilatation with all the 
symptoms as previously described, including cyanosis, visceral conges- 
tions, and dropsies. The murmur at the apex, due to incompetency 
from dilatation, may simulate chronic valvular disease, although the 

43 



674 SPECIAL DIAGNOSIS. 

latter may never have been present. The sclerosis ma) T advance more 
rapidly in the kidneys than in the other portions of the circulation ; 
later, on account of the contracted kidney, symptoms of interstitial 
nephritis may arise. 

Aneurism. 

A true aneurism is formed by the distention of one or more of the 
arterial coats. It is usually fusiform, but may be cylindrical. It may 
be circumscribed or sacculated. The fusiform and saccular are the 
forms most commonly seen. False aneurism or dissecting-aneurism 
arises from laceration of the internal coat of the artery. The blood 
dissects between the layers. It occurs in the aorta. It may begin at 
the heart and separate the coats as far down as the iliac arteries. 
Arterio-venous aneurism is seen when communication between an artery 
and a vein has been set up. If a sac intervenes, it is called a vari- 
cose aneurism. Sometimes communication is direct, the vein becoming 
dilated, tortuous, and pulsating. It is known as an aneurismal varix. 

An aneurism may occur in the course of arterial sclerosis from 
diffuse distention of the coats. Its typical form is seen in dilatation of 
the aorta with one or more sacculated aneurisms on its surface. 

Sacculated aneurism occurs from rupture of the tunica media, indepen- 
dently of general disease of the arteries, and in arterial sclerosis. The 
most common seat is the ascending portion of the aorta. It occurs 
early in the course of arterial sclerosis. Such form of aneurism is 
seen in the smaller vessels. Aneurisms also arise after the lodgement 
of an embolus, permanently plugging the vessel. The proximal end 
of the vessel becomes dilated. 

Mycotic aneurism, first described by Osier and exhaustively by 
Eppinger, occurs in malignant endocarditis. The aneurisms are small 
in size and multiple, and not recognized during life. They arise from 
the injury produced by the local infection of bacteria in different por- 
tions of the vascular system. 

Aneurism of the Thoracic Aorta. The causes which produce 
arterial sclerosis are operative in the thoracic portion of the aorta — 
chiefly physical overwork, alcohol, syphilis, and gout. It may be 
situated just beyond the aortic ring, at the junction of the ascending 
and transverse aorta, in the transverse, or at the beginning of the 
descending, portion of the thoracic aorta. The larger aneurisms are at 
the two bends of the aorta. 

Symptoms. The symptoms of aneurism are largely due to press- 
ure, and depend upon the position of the aneurism and the direction of 
its growth. 

Aneurisms, however, may exist without symptoms or appreciable 
physical signs. Even in a patient who has been under careful obser- 
vation, sudden death may take place from rupture of a concealed 
aneurism, the presence of which had not been suspected during life. 
On the other hand, cases occur with characteristic pressure-symptoms 
and with no physical signs. Pressure -symptoms depend entirely upon 
the position of the tumor. 

Aneurisms of the ascending portion of the arch cause dislocation of 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 675 

the heart outward, or toward the right pleura or forward, appearing 
at the second or third interspace, causing erosion of the ribs and ster- 
num. The vena cava is compressed, causing enlargement of the veins 
of the head and arms ; the subclavian vein may be compressed alone, 
causing enlargement and oedema of the right arm. Localized oedema 
may result, confined to the thorax. (See CEdema.) If the aneurism 
is large, the inferior vena cava may be pressed upon, causing oedema 
of the feet. The right laryngeal nerve may be involved, causing 
aphonia and dyspnoea. Pain attends the aneurismal process. 



Fig. 177. 




Aneurism of ascending portion of arch of aorta. Tumor in first and second interspaces, 
extending into neck. Portion of sternum atrophied. 



Aneurisms of the transverse portion of the aorta project below, for- 
ward, or backward. When forward, they produce tumors behind the 
manubrium, which from pressure cause destruction of the bone ; if the 
aneurism projects backward, marked pressure-symptoms are produced. 
When the trachea is pressed upon, it causes dyspnoea and cough, which 



676 SPECIAL DIAGNOSIS. 

is paroxysmal. (See Dyspnoea.) The oesophagus may be pressed 
upon, causing dysphagia. The left recurrent laryngeal nerve may be 
pressed upon, causing paralysis of the corresponding cord, with aphonia. 
(See Larynx.) Pressure on a bronchus may produce bronchorrhoea 
and dilatation, which in turn may lead to localized abscess. The 
growth may extend upward, involving the coats of the innominate and 
carotid arteries on the right side, or carotid and subclavian on the left, 
markedly interfering with the pulse of the two sides. Pressure on 
the sympathetic nerve is likely to take place in this situation, with 
contraction of one of the pupils, although at first it is sometimes 
dilated. The thoracic duct is sometimes compressed, leading to rapid 
wasting. 

In the descending portion the pressure-signs of aneurism are often not 
so marked. The vertebra? are likely to be pressed upon in this situation. 
The pain, therefore, is most intense. The oesophagus and left bronchus 
are compressed. Dysphagia and bronchiectasis, the latter causing 
bronchorrhoea with subsequent gangrene, are likely to occur. The 
cough and the fever in bronchorrhoea, together with emaciation, simu- 
late phthisis, for which aneurism is often mistaken. The physical 
signs of phthisis are usually pronounced in this situation, and, with the 
presence of bacilli in the sputum, render the diagnosis easy. In these 
cases rupture takes place into the bronchus or into the oesophagus. 
In one of my cases, which had been treated for tuberculosis because of 
small hemorrhages, with the conditions above-mentioned, death took 
place from rupture into the bronchus, causing sudden profuse hemor- 
rhage. When the aneurism is adherent to the oesophagus and slowly 
ulcerating into it, rupture may take place, followed by instantaneous 
death. The vertebrae may be eroded and symptoms of spinal com- 
pression arise. 

I once saw an autopsy performed by a medico-legal expert on a case of 
sudden death from gastric hemorrhage. The source of the hemorrhage 
could not be ascertained. There was blood in the stomach. When he 
was about to give up the search, the oesophagus and aorta were sug- 
gested for examination. A small aneurism was found which had 
ulcerated and then ruptured into the gullet. In another the aneurism 
had ruptured into the pleural sac, causing internal concealed hemor- 
rhage and death. 

Special Symptoms. While pressure-symptoms are the most striking 
symptoms of this affection, pain, which is usually due to pressure, 
must be referred to. It is an important constant symptom. It is 
sharp and lancinating, and may occur in paroxysms. It is more 
severe and constant when bone is eroded by pressure on the vertebrae, 
or the thorax in front. The gnawing pain that attends ulceration of 
bone is relieved, if it, as the sternum, is perforated. Anginal attacks 
may attend the neuralgic pains just described. Pain sometimes fol- 
lows the course of the nerves, extending down the arm or to the neck, 
or along the course of the intercostal nerves. 

Cough. The cough is peculiar. It is paroxysmal in many cases 
and of a brazen, ringing character, indicating its laryngeal origin, due 
to pressure upon the recurrent laryngeal nerves. It is frequently 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 677 

paroxysmal when the pressure is directed upon the windpipe or bron- 
chus. In the former instance the cough is dry, in the latter tracheal 
and bronchial. It is attended by a thin, watery expectoration which, 
if bronchiectasis with fermentation ensues, becomes thick and ropy. 
Dyspnoea occurs more frequently in aneurism of the transverse portion, 
due (1) to pressure on the recurrent laryngeal nerves ; (2) to compres- 
sion of the trachea ; (3) to compression of the left bronchus. Marked 
stridor attends the first form. When one of the recurrent laryngeal 
nerves, more particularly the left, is pressed upon, there is spasm or 
paralysis of the muscles of the vocal cord, causing hoarseness and loss 
of voice. Laryngoscopic examination should not be neglected, for 
paralysis of the abductor muscles without symptoms may be present. 

Hemorrhage. The hemorrhage may be gradual when there is 
slight leakage into the trachea at the point of compression. The 
amount of blood lost is small. It may take place externally. (See 
Fig. 178.) Profuse hemorrhages, causing sudden death, occur from 

Fig. 178. 




Aneurism of ascending and transverse portions of aorta projecting forward, destroying ribs and 
sternum. The skin ulcerated, and gradual external leakage took place. The bleeding continued 
in small amounts for a long time. 



rupture into the trachea or bronchus, and from perforation into the 
lung. With regard to difficulty of deglutition, it may be said that the 
sound should never be passed in suspected cases of aneurism, on 
account of the danger of rupturing the sac. 

Clubbed Fingers. In intrathoracic aneurism clubbing of the fingers 
and incurvation of the nails of one hand are sometimes seen, although 
comparatively rarely. 

Compression and pressure on the sympathetic system of nerves has 
been referred to. In addition to pupillary changes there may be pallor 



678 



SPECIAL DIAGNOSIS. 



of one side of the face. When the pupil is dilated this pallor may 
accompany it, on account of stimulation of the vaso-dilator fibres. 
When the cilio-spinal branches of the sympathetic are pressed upon, 
the dilator fibres are paralyzed. If the pupil contracts, there are also 
hyperemia of the side of the face and unilateral sweating. 

Physical Signs. (Plate XXXIV., Fig. 1.) Inspection. In 
health the position of the aorta cannot be recognized. Pulsation may 
be seen at the episternal notch in rare instances, particularly in women, 
independently of disease of the aorta ; it is due to nervous palpitation. 
An aneurism may exist without any external visible signs. On the 



Fig. 179. 




Aneurism. General endarteritis and valvulitis. 
TR. = Thrill and impulse. + = Murmur. 



other hand, pulsation may be seen at either side of the sternum above 
the level of the third rib, most commonly in the second interspace on 
the right side. The impulse may be seen alone without visible swell- 
ing ; the chest must be viewed from different situations in order to 
detect it. An oblique light falling on the surface is sometimes neces- 
sary. When the innominate artery is involved the pulsation is observed 
in the neck, above the sterno-clavicular junction, or above the sternum. 
With the abnormal impulse a swelling or tumor is often present. 
It may be large enough to press the upper portion of the sternum and 
adjacent ribs forward. In other instances a tumor the size of the half 



PLATE XXXIV. 




V] 



\\ 



wk 



Aneurism of the Arch of the Aorta. 
fto. 2. 
Tumor /' \\ 




W* 



W 



Tumor of the Anterior Mediastinum. 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 679 

of a lemon may be seen along the edge of the sternum. The most fre- 
quent site is the first and second right, or the second left interspace. 
The skin over the tumor, as in the case of which an illustration is 
given, may ulcerate and be the seat of persistent small hemorrhages. 
The apex-beat of the heart is displaced downward and outward from 
pressure. 

If the aneurism is seated in the ascending portion of the aorta, just 
beyond the aortic ring, a pulsating tumor may be seen in the third 
interspace at the left edge of the sternum. If in the ascending por- 
tion, beyond the heart, the tumor is in the first or second interspace 
along the right edge of the sternum. If the aneurism is in the trans- 
verse portion of the aorta, the upper portion of the sternum is fre- 
quently made to protrude, or the tumor projects upward into the fossse 
of the neck. If in the descending portion, it is in the second or third 
interspace on the left side. In this portion of the aorta a tumor is 
seen in the left scapular region in rare instances. 

Palpation. Palpation must be employed by the usual method ; 
bimanual palpation must also be used, one hand placed upon the ster- 
num and the other upon the vertebra?. Moderate pressure should be 
exerted. Palpation should also be employed at different periods of 
respiration. At times signs are only yielded at the end of complete 
expiration. It must further be said that palpation must be employed 
both with the tips of the fingers and with the palm of the hand applied 
to the surface. 




Possible position of impulse in aneurism ; arranged in order of frequency. 

By palpation the area and degree of pulsation are determined. If 
the aneurism is large or has perforated, the impulse is expansile and 
heaving in character. The sac may be soft and fluctuating, but usually 
presents considerable resistance. In addition to the systolic impulse 
the diastolic shock is also felt. This is a most conclusive physical 
sign. A thrill is frequently present, systolic in time, usually due to 
dilatation of the arch ; at times, to sacculated aneurism. Without 
visible tumor, pulsation and thrill may be felt in the suprasternal 
notch, if the head is bent forward, so that the tissues are relaxed, and 



680 SPECIAL DIAGNOSIS. 

the fingers pushed down toward the aorta. When the aneurism is 
filled or filling with clot, the tumor may be seen and felt, but no im- 
pulse will be transmitted to the hand or thrill be felt by the fingers. 

Percussion. Percussion furnishes the most reliable evidence of the 
presence of an aneurism or aneurismal dilatation in cases in which the 
tumor is not too deep-seated or small in size. The dulness may be 
relative only. (See Cardiac Percussion.) The area of dulness is 
increased somewhere in the course of the aorta. It may be observed 
projecting outward at the right edge of the sternum when the ascend- 
ing portion of' the aorta is the seat of disease, or over the entire upper 
part of the sternum, extending toward the left, when the transverse 
portion is diseased. It may be observed as an extension of cardiac 
dulness upward in the second and third interspaces. Sometimes dul- 
ness is detected in the scapular regions, particularly of the left side. 
The percussion-tone is flat, and there is marked sense of resistance. 
Percussion must be employed with the patient in the upright and in 
the recumbent posture. 

Respiratory Percussion. The character of the tone and the shape of 
the dulness must be noted at the end of full inspiration and of full 
expiration. 

Fig. 181. 




Aneurism of aorta. 
Area of absolute dulness, dark line. Area of relative dulness, broken line. 

Auscultatory percussion is of the utmost value, and the method of 
percussion taught by Sansom and Ewart must be carefully followed. 
An aneurismal tumor may be present without thrill or murmur, but 
yields signs of dulness on percussion. 

Auscultation. As just stated, murmurs may not always be pres- 
ent. They depend upon the amount of fibrin in the sac. When pres- 
ent the murmur is systolic in time, heard with maximum intensity 
usually over the abnormal area of impulse or tumor, or over the in- 
creasing area of dulness. It is transmitted in the direction of the 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 681 

vessels, and may be heard louder in the vessels of the neck and along 
the course of the aorta. Often a double murmur is heard, the diastolic 
sound being due to associated regurgitation at the aortic orifice. Some- 
times the diastolic murmur alone may be heard. Increase in intensity 
or accentuation of the aortic second sound is pronounced. The sound 
is ringing in character, and is rarely absent in large aneurisms. 

The Peripheral Vessels in Aneurism. The pulse in the two radial 
arteries may show a marked difference both in volume and in time. 
The difference may indicate the position of the aneurism. If the 
pulse of the right radial is smaller than the left, the aneurism may 
be in or near the innominate artery ; if the opposite, it is near or in- 
cludes the orifice of the left subclavian. In the same way the differ- 
ence in time may also aid in determining the location. Osier refers 
to obliteration of the pulse in the abdominal aorta and its branches. 
In one case he could not feel throbbing in the aorta and the femorals, 
although the circulation was unimpaired. The aneurism was in the 
descending portion of the aorta, and its pulsation was seen in the left 
scapular region. The sac was sufficiently large to act as a reservoir, 
which filled during the ventricular systole, and from which the blood 
poured toward the periphery in a continuous stream instead of being 
intermittent. 

Tracheal Tugging. Tracheal tugging may be obtained in one of two 
ways. By the old method the patient should be sitting or standing, 
while the observer sits or stands to one side, and faces him. With the 
hand furthest from the patient steadying the head, the observer gently 
but firmly grasps the surface of the cricoid cartilage with the thumb 
and finger of the other hand, while the head is slightly thrown back. 
The head is then flexed, so that the neck is no longer stretched. The 
patient is then told to hold his breath completely, and any up-and-down 
movement of the trachea is immediately transmitted to the observer's 
fingers. One must not mistake the transmitted pulsation in the 
cervical vessels for such movement ; and great care should be exer- 
cised to see that the breathing is entirely stopped. 

In the other method, as proposed and practised by Ewart (British 
Medieal Journal, March 19, 1892), the observer stands behind the 
patient, steadying the latter' s head against his body, and the cricoid is 
firmly held between the tips of the first or middle fingers. The 
writer, after considerable experience, prefers this second method, on 
account of delicacy of touch, firmness of grasp, and comfort to the 
patient. 

Diagnosis. The special points of diagnosis are : the etiological 
factors ; the antecedent pathological conditions, as arterial sclerosis ; 
the occurrence of pain ; the occurrence of pressure-symptoms ; and 
the physical signs. These have been sufficiently dwelt upon, and it is 
not necessary to consider them again. It must not be forgotten that 
aneurism may be present without diagnostic physical signs, and, on 
the other hand, the pressure-symptoms may also be in abeyance. If 
one of the two is present in the male subject past forty, with a pre- 
vious history of syphilis, gout, alcoholism, or muscular strain, the 
probability is that an aneurism exists. The pressure-symptoms 



682 



SPECIAL DIAGNOSIS. 



always point to some form of intrathoracic disease as the cause of this 
group of symptoms. Thus, in cancerous disease of the lymphatic 
glands, or other tumors within the mediastinum, pressure-symptoms 
exactly simulating aneurism may be present and also the physical signs 
of a tumor. The tumor, however, rarely projects externally, and still 
more rarely pulsates. If pulsation is present, it is not of the expan- 
sile character seen in aneurism, nor is there as decided a systolic shock 
when the ear is held against the chest. By the same method we ob- 

FlG. 182. 




X-ray appearance in aneurism. (Pepper and Leonard.) 

serve the shock of the heart-sounds, which are notably lessened or 
absent in tumors from other causes than aneurism. In deep-seated 
tumors with pressure-symptoms the condition of the arteries, apart 
from aneurism, is of diagnostic importance. Accentuation of the 
aortic second sound, with hypertrophy of the heart, points to aneu- 
rism. The presence of tracheal tugging is also a valuable diagnostic 
point in its favor. In tumor, and especially in cancer, there are 
emaciation and development of a cachexia, which is, as is well known, 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 683 

most pronounced in cancer of the oesophagus. Cancer of the oesopha- 
gus, from its frequent point of election near the left bronchus, often 
simulates the pressure-symptoms of aneurism. 

Aneurism must be distinguished from the pulsation of the aorta 
which is seen in aortic regurgitation. This pulsation is usually asso- 
ciated with dilatation, the latter causing increased dulness, which may 
add further to the confusion. Exaggerated pulsation without dilata- 
tion may, as Bramwell has recorded, be the cause of dulness and pul- 
sation over the aorta. The subjects are under forty, neurotic, and 
usually anaemic. 

It is not, as a rule, difficult to distinguish between pulsating empy- 
ema and aneurism. Wilson points out that aneurism bears a definite 
relation to the central long axis of the chest. The area of dulness of 
aneurism is circumscribed, and is usually the seat of murmurs or other 
sounds synchronous with the rhythm of the heart. The signs of pul- 
sating empyema are usually upon the left side and at a distance from 
the median line. The percussion-dulness is at the base of the chest and 
quite extensive. Arterial murmurs are not present. The pulsation 
is influenced by pressure and by respiratory movements. 

In mediastinal cancer we are aided by the discovery of enlargement 
of the glands in the axillary or some other situation, or by a history 
of the growth elsewhere. 

Aneurism must not be confounded with phthisis. The diseased 
vessel may occlude a bronchus and cause collapse and bronchial dila- 
tation ; hemorrhage may occur ; bronchorrhoea and cough always 
ensue. Fever is not marked, which fact, with tracheal tugging, vas- 
cular physical signs, and the absence of tubercle bacilli, points to 
aneurism. 

X-ray Examination. By virtue of the large amount of blood in an 
aneurism, the tumor is not pervious to the X-rays, and in consequence 
is readily seen by fluoroscopic examination. Williams and others have 
been very successful in recognizing an aneurism even when it could 
not be made out by physical signs. Such examination must be resorted 
to in all cases. (Fig. 182.) 

Diseases of the Mediastinum. 

Inflammation of the mediastinum may be limited to the glands or 
the connective tissue. Moderate inflammation of the glands, lymph- 
adenitis, occurs in bronchitis and pneumonia, particularly if bronchitis 
is of specific origin, as in measles or influenza. It is said that such 
inflammation is of common occurrence in whooping-cough, and may 
be the exciting cause of the paroxysms. DeMussy and Guiteras have 
found physical signs of enlargement, characterized by dulness in the 
upper part of the interscapular region, in cases of this disease and of 
influenza. Other authorities, as Osier, dispute the possibility of this 
occurrence, or at least of its recognition by physical signs. Tubercu- 
lous inflammation of the lymphatic glands of the mediastinum may 
give rise, however, to local physical signs. Abscess of the glands 
cannot be distinguished during life. 



684 SPECIAL DIAGNOSIS. 



Tumors of the Mediastinum. 

Cancer and sarcoma are the most frequent forms of tumor in this 
locality. Hare found the proportion in 520 cases to be as follows : 
134 of cancer, 98 of sarcoma, 21 of lymphoma, 7 of fibroma, 11 of 
dermoid cyst, 8 of hydatid cyst, and the remainder of lipoma, gumma, 
and enchondroma. With the application of more correct histological 
methods we now know that sarcoma is more common than carcinoma. 
The tumor is most frequently found in the anterior mediastinum when 
one region alone is affected. The disease may be either primary or 
secondary. In sarcoma it is usually primary. Males are chiefly 
affected, and most often between thirty and forty. The thymus gland, 
the lymphatic glands, the pleura, or the oesophagus is the source of 
origin in all cases, the former the most frequent. 

The symptoms of mediastinal tumor are chiefly due to pressure. 
Dyspnoea is early and constant, and may be laryngeal, or tracheal 
from pressure on that tube. In some instances encroachment upon 
the heart or the vessels causes dyspnoea. Again, the dyspnoea may 
be due to a pleural effusion which accompanies the growths. Cough 
of a peculiar character occurs. It is laryngeal, and of a dry, brazen 
quality. Aphonia may arise from pressure upon the recurrent laryn- 
geal nerves. (See Diseases of the Larynx.) If the bloodvessels are 
pressed upon symptoms of obstruction occur, depending upon the ves- 
sel occluded. CEdema of the upper extremities may occur. If the 
oesophagus is pressed upon, there is difficulty in deglutition. In some 
instances the sympathetic nerve is pressed upon, causing hypersemias 
and pupillary changes. 

The physical signs (Plate XXXIV., Fig. 2) are those of a tumor 
in the anterior portion of the chest, frequently in the prsecordial area, 
which may or may not pulsate ; dislocation of the heart, not limited 
to any position ; great dulness and resistance ; frequently conduction 
of lung-sounds and heart-sounds to some distance ; at times a systolic 
murmur ; increased size and pulsation of the veins ; and physical signs 
from pressure. (See Aneurism.) It must be remembered that pain is 
more common in aneurism, fever and emaciation in mediastinal growths. 

Tumors of the anterior mediastinum present the physical signs, in 
front, of a prominence more or less marked, often including projection 
of the sternum ; an irregular area of dulness ; rarely transmitted pul- 
sation ; more frequently transmitted heart-sounds and lung-sounds. 
It is the form in which phenomena from pressure upon the veins are 
most marked. Symptoms from arterial pressure (difference in pulse), 
pressure on the vagus and sympathetic are less frequent. Dyspnoea 
may occur. 

Tumors of the middle and posterior mediastinum are characterized by 
pressure upon the bronchi and structures adjacent thereto, hence we 
have symptoms from pressure upon the oesophagus, aorta, and the nerves. 
Dyspnoea and cough are the most pronounced symptoms, while phe- 
nomena from pressure on the vagus, cardiac palpitation, vomiting, 
etc., are not uncommon. Emaciation and a cachexia are more marked 



DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 685 

than in tumors in other regions. Pepper and Stengel consider that 
fever attends growths in this region with greater frequency. 

Tumors of pleural origin have symptoms of acute or subacute pleu- 
ritis, with or without effusion. The fluid secured by puncture is 
usually bloody, rarely chylous, and may contain suspicious vacuolated 
epithelial cells. A mass may be suspected if there is great resistance 
to the trocar. If the tumor ulcerate into the lung, the sputa may con- 
tain characteristic groups of cells, while hemorrhagic oozing may be 
suspicious. 



CHAPTER IV. 

DISEASES OF THE MOUTH, FAUCES, PHAEYNX, AND 
(ESOPHAGUS. 

The Mouth. 

The mouth is affected by comparatively few diseases, and most of 
these are the result of infection or of trauma, or, rarely, are tropho- 
neurotic. The cavity forms a good breeding-place for all forms of 
organisms, and were it not for the secretions and constant cleansing of 
the mouth by the passage of food and its physiological labors, diseases 
would be very common. Indeed, it is possible that such diseases do 
not take place at all unless there is such perversion of the normal 
secretion as destroys its antiseptic or antimicrobic qualities. We know 
but little specifically concerning the changes in the secretions. Clini- 
cally, we do know, however, that in conditions of poor nutrition, in 
wasting diseases generally., and probably in connection with the rheu- 
matic diathesis, there is such change in the secretions as permits patho- 
genic micro-organisms to exercise their influence upon the mucous 
membrane. The result of their action is seen in various forms of in- 
flammation. 

Symptomatology. The symptomatology of mouth-affections is 
the symptomatology of inflammation : pain, heat, redness, and swelling. 

The Data Obtained by Inquiry. 

The subjective symptoms are not characterized by great gravity, 
but they are most annoying. 

Pain. This symptom is most aggravating, because it is excited by 
the many functional acts connected with the mouth. It occurs in all 
inflammations and ulcerations except those due to syphilis. It is 
aggravated by food, by movements of the lips, cheeks, or tongue, and 
by attempts to discharge saliva. The absence of pain is observed in 
gangrene. 

Heat. The patient complains of heat of the mouth in inflammations. 

Dryness. This symptom is complained of in fevers, and by those 
who are compelled to sleep with the mouth open. It may be a condi- 
tion of itself, as the following shows : 

Dry Mouth. Xerostoma. Hutchinson first described a condition 
of the mouth in which dryness was the chief complaint. The secre- 
tions arc suppressed entirely, the tongue red and dry, the mucous mem- 
brane of the cheeks and palate smooth, shining, and dry. Functional 
movements are very difficult. The majority of the cases are in women 
in whom the general health is always impaired. Hay den thinks that 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 687 

the secretion of the salivary and buccal glands is modified as the result 
of a central nervous disturbance. In xerostoma there is also dry- 
ness of the nostrils and eyes, with intolerable itching. In a case which 
Harris reported both parotid glands were enlarged and firm but painless. 
There is some dryness of the mouth in fevers. It is also symptom- 
atic of chronic gastritis, and may occur in diabetes. 

The Data Obtained by Observation. 

The objective symptoms are determined by inspection and palpation. 

By these means we observe the color of the parts of the mouth, 
changes in temperature, as well as in the size and shape (swelling). 
The teeth, gums, and tongue are also examined. 

Color. The normal redness of the mucous membrane may be in- 
creased or diminished in intensity. Pallor is associated with anaemia. 
Increased redness attends inflammation, and with it the temperature 
is raised. The mucous membrane is yellow in jaundice, bluish in 
cyanosis. Both of the latter changes are observed to greater advan- 
tage under the tongue. The mucous membrane is the seat of pig- 
mentation in Addison's disease and in argyria. In the former, small 
oval purplish spots are seen. They must not be confounded with the 
pigmented spots common after stomatitis in negroes. Eruptions occur 
in the mouth and may precede external eruptions. This is notably so 
in measles. In this affection the eruption is seen on the hard and soft 
palate twenty-four hours before the development of the rash. In 
smallpox and chickenpox the vesicles are seen. 

Shape. Swellings are seen usually as the result of disease of struc- 
tures about the mouth. The floor of the mouth is encroached upon by 
glands underneath or by swelling of the cellular tissue. Bone diseases 
and some teeth affections cause swellings. The dental arch must be 
observed. Narrowing of the arch is due to adenoid disease or to the 
habit of thumb-sucking in childhood, much more likely the former. 

Foetor. The odor imparted to exhaled air is peculiar in mouth- 
affections. It may be a simple foetor or of a metallic or gangrenous 
odor. Foetor attends all inflammations ; it is more pronounced in 
ulcerative and mercurial stomatitis. In the latter it may be metallic. 

Hemorrhage. Petechia? in purpura hemorrhagica ; submucous hemor- 
rhages in scorbutus and severe forms of purpura — morbus maculosus 
werlhojii — are common on the cheeks and on the gums. In ulcerative 
endocarditis hemorrhagic infarcts are seen. In grave anaemias petechia? 
are also seen. 

Capillary oozing of blood takes place from the mucous membranes 
in low typhoid states. The accumulated blood collects about the 
teeth, on the tongue, etc., and in febrile states becomes dry. Dry 
incrustations are known as sordes. 

Salivation. Increased flow of saliva occurs in all inflammations 
unless attended by high fever. It may be constantly discharged by 
the patient or dribble in a continuous stream. (See Saliva.) 

Secretions of the Mouth. The Saliva. The saliva is derived from the 
parotid, submaxillary, and sublingual glands, and from the mucous 



688 



SPECIAL DIAGNOSIS. 



glands within the mouth. The mouth should be washed with a warm 
alkaline solution and afterward with cold water, in order that the saliva 
obtained may be perfectly pure for examination. After the washing the 
glands may be stimulated by the application of dilute acid on a glass 
rod. The normal amount secreted in twenty-four hours varies from 
two to three pints. It is of a light bluish color, or colorless. It is 
somewhat stringy. On standing, two layers form in a conical glass, 
the upper clear, the lower cloudy. The reaction of saliva is alkaline. 

Microscopical Examination. The following formed elements are 
observed : 1. Salivary corpuscles of the appearance of, but larger and 
more granular than, a white corpuscle. 2. Epithelium. The squa- 
mous variety derived from the mouth is seen. The cells are large in 
size and of polygonal shape. 3. Fungi. In health the mould and 
yeast fungi are seldom found. In disease they are present in large 
numbers ; fission-fungi are met with in great numbers, both in health 
and in disease. In health small and large colonies of micrococci are 
found along with abundant bacilli. Miller has studied the micro- 
organisms of the mouth carefully and exhaustively (see The Dental 
Cosmos), both by microscopical examination and culture-methods. 
The following are found to be pathogenetic : (1) The leptothrix buc- 
calis ; ( 2) vibrio buccalis ; (3) spirochete dentium ; (4) micrococcus 
tetragenus ; (5) the micrococcus de la rage ; (6) the micrococcus of 
sputum septicemia ; (7) the bacillus of decaying teeth, three varieties 
of the staphylococcus ; (8) the bacillus crassus sputigenus ; (9) the 
bacillus salivarius septicus and bacillus septicus sputigenus. 



Fig. 183. 




Buccal secretion. (Eye-piece III., obj., Reichert, 1/15, homogeneous immersion ; Abb6 illumina- 
tion, open condenser.) Friedlander's and GUnther's method. (Von Jaksch.) 

a, epithelial cells; 6, salivary corpuscles; c, fat-drops ; d, leucocytes; e, spirochsete buccalis; 
/, common bacilli of mouth ; g, leptothrix buccalis ; h, i, k, different fungi. 

Of course, in the saliva the thrush-fungus, actinomyces, the tubercle 
bacillus, and the bacillus of diphtheria are found. It must not be 
forgotten that the diplococcus pneumoniae or micrococcus lanceolatus, 
which is the specific cause of pneumonia, is found in the saliva of some 
persons in health. It is also called the bacillus sputi septicemici. 

Chemical Examination. The chemical characters of the secretion 
depend upon the activity of the different glands. The saliva con- 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 689 

tains a trace of albumin, found by heating ; a ferment which changes 
starch into sugar ; mucin ; and occasionally sulphocyanide of potas- 
sium. In disease, as the quantity is diminished rather than increased, 
examinations have rarely been made. In ptyalism the saliva should 
be collected after rinsing the mouth frequently, especially after eating. 
The reaction is found to be alkaline, and the specific gravity low, 1002 
to 1006. Albumin is tested for by the usual methods. The sulpho- 
cyanides are detected by a solution of chloride of iron. When this is 
added to the fluid a bright red color appears which does not disappear 
with heat ; a similar color, due to the precipitation of meconic acid, 
may be obtained by the same test from the saliva in opium-poisoning. 

Sugar is tested for by the methods used in the examination of the 
blood. The diastatic ferment is detected by adding 5 c.cm. of saliva 
to 50 c.cm. of starch solution and placing the mixture in a warm 
chamber or a water-bath heated to 40° C. After an hour's time the 
fluid will show the presence of grape-sugar. Nitrites are detected by 
adding a little saliva to a mixture of starch paste, iodide of potassium, 
and dilute sulphuric acid. If the nitrites are present, a blue color 
results. 

Saliva in Disease. In catarrhal stomatitis the secretion is in- 
creased. It is acid and contains epithelium in excess. In ulcerative 
stomatitis it is also increased, is of a dark-brown color, foetid, and alka- 
line. It contains degenerated epithelium, leucocytes, blood-corpuscles, 
and many forms of fungi. It is increased in pregnancy, in rabies, and 
in glosso-labio-laryngeal palsy. I have seen it in excess in the con- 
valescence of typhoid fever. It is increased by the internal use of 
jaborandi. 

Fig. 184. 




■}.:> 



O'idium albicans, the vegetable parasite of muguet or thrush. (Reduced from Ch. Eobin.) 



The reaction becomes acid in diabetes, gout, rheumatism, and mer- 
curial poisoning. Urea may be found in cases of nephritis, particu- 
larly in uraemia. There is no sugar in diabetes. Fenwick has inves- 
tigated the changes in the sulphocyanide of potassium in disease. By 
a scale of colors he was enabled to compare the saliva in which sulpho- 
cyanide of potassium had been detected in health with the saliva in 
various diseases. He believes that the amount of this ingredient is 
indicative of the degree of functional activity of the organs of nutri- 

44 



690 



SPECIAL DIAGNOSIS. 



tion. It is increased in acute inflammation and in the earlier stages of 
cancer and phthisis ; in acute congestion of the liver from stimulants 
or food excess ; and in rheumatism, gout, and the convalescence of 
typhoid fever. Where the power of the nutritive organs is diminished 
the sulphocyanide of potassium is lessened, as in late phthisis and 
cancer, the later stages of chronic diarrhoea and dysentery, chronic 
catarrhal jaundice, in ascites, and in the passive congestion of the 
abdominal viscera. Fenwick believes that tedious recovery and fre- 
quent relapses will occur if this element is found in excess in acute 
rheumatism. 

Thrush. The fungus peculiar to this disease is found. Saliva is 
increased ; it is usually acid. The disease is characterized by the 
formation of small patches on the mucous membrane, which in a few 
days coalesce and form a mass which may cover the entire mouth and 
extend to the fauces. Before coalescing they are firmly adherent. 
Subsequently they loosen. On microscopical examination, in addition 
to epithelial cells, leucocytes, and unorganized elements, the character- 
istic parasite is seen. It is of ribbon-shape, varying in length, and 
composed of long segments which often contain highly refractive nuclei 
at either end. The segments are homogeneous ; they vary in length, 
those nearest the extremities being somewhat shorter. When mounted 
in glycerin they are readily seen. Spores are also seen. 

The Leptothrix Buccalis. The latter is seen in ribbon-like bundles 
composed of numerous segments ; it stains a bluish-red in potassic iodide 
solution. It is most frequently seen in the tartar of the teeth. 



Fig. 185. 




Leptothrix buccalis from the gums at edges of teeth. X 350. 
a, the filaments separated ; b, masses of filameuts. 



The Gums. The gums and the mucous membrane of the mouth are 
involved in inflammations and ulcerations, and in certain metallic 
poisonings. The gums swell and grow spongy in inflammations. 

The Gingival Line. In cases of tuberculosis a red line at the 
junction of the gums and the teeth is frequently seen. At one. time it 
was thought to be of diagnostic value. It is seen, however, in other 
cachectic conditions, as carcinoma, and at times in diabetes. 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 691 

The Gums in Scurvy. In scurvy the gums are swollen and spongy. 
They bleed easily, and are usually streaked with blood. Ulcers form 
along the margin of the teeth. There is not much foetor of the breath. 
In mild cases the inflammation may be limited to the gums of four 
or five teeth. The gums of decayed teeth are usually the seat of the 
most marked inflammation. Infants may have scurvy as well as 
adults — especially if fed exclusively on sterilized milk or malt prepa- 
rations. (See Scurvy-rickets.) 

The Gums in Lead-poisoning. The Blue Line. In lead-poisoning 
a blue line is seen at the margin of the gums. The line is preceded by 
a row of separate black dots occupying the seat of the papillse of the 
mucous membrane. If examined with a magnifying glass, the line is 
readily seen to be an interrupted one. It does not always extend 
along the entire margin, but may be limited to a few front teeth in either 
the upper or lower jaw. In the more advanced cases there is some 
salivation and a sweetish metallic taste in the mouth and metallic foetor 
of the breath. 

The Teeth. In all diseases of the gastro-intestinal tract it is im- 
portant to investigate the state of the teeth. Cases of indigestion are 
often due to defective mastication, rendered so by decayed teeth. Per- 
sistent aural, nasal, and ophthalmic affections may have their primary 
origin in disease of the teeth. Caries of the teeth may cause headaches 
or neuralgias, near or remote (see Headache), and may explain many 
cases of foul breath. Pitting of the surface of the teeth and thinning 
of the enamel in transverse grooves are held by some to be due to mer- 
cury. There is no doubt that infantile stomatitis, independent of mer- 
cury, is the cause of these changes. They must be distinguished from 
the so-called Hutchinson's teeth. In stomatitis the molars are often 
honeycombed to an extreme degree, the incisors becoming affected 
next. In addition to pitting and erosion the color may be darker. A 
transverse furrow crosses all the teeth at the same level. 

The Teeth in Gout. Erosion of the teeth takes place in gouty sub- 
jects. There are wasting and loss of polish of the labial surface, fol- 
lowed by deep grooves which extend into the body of the teeth. 
Pyorrhoea alveolaris is another expression of gout. There is, first, 
usually a marginal inflammation of the gums ; second, inflammation 
and necrosis of the pericementum ; third, loosening of the teeth and 
the formation of so-called calculi. 

The Teeth of Congenital Syphilis. The upper central incisors of the 
permanent set are affected. They are dwarfed, narrowed, and short. 

Fig. 186. 



voter 



Notched teeth. Malformation of permanent teeth found in hereditary syphilis. 
(Mr. Jonathan Hutchinson.) 

The middle lobe of the tooth is so atrophied as to leave a single 
broad vertical notch in the edge of the tooth. A narrow furrow some- 



692 



SPECIAL DIAGNOSIS. 



times passes upward from the notch on both anterior and posterior sur- 
faces, nearly to the gum. It is seen from the above that the appear- 
ances of the permanent teeth may be an index of the condition of 
nutrition of the child in infancy. 

Teething. During the period of infancy it is well to remember 
the influence of the eruption of the teeth upon the general constitution. 
While many prominent authorities believe that the eruption takes place 
without the occurrence of general or reflex symptoms, equally careful 
observers, on the other hand, believe that nervous phenomena often 
attend the process. The latter class of observers attributes the fever- 
islmess, insomnia, restlessness, loss of appetite, and gastro-intestinal 
disturbance to this cause. Convulsions at this period are believed to 
be due to the pressure of the tooth, which cannot break through the 
mucous membrane, upon highly sensitive nerves at the root. Even in 
later life reflex convulsions are held by some to be due to the teeth. 

Slowness in the development of the teeth may be due to rhachitis, 
which should be looked for. The student should be familiar with the 
periods of development, the number of teeth that appear at each period, 
and the date of the eruption. 

Dates of Eruption op the Teeth. 

Milk Teeth. 



2M 1C 41 1C 2M 



2M 1C 41 
Eruption of central incisors about 
lateral incisors *' 
" first molars ' ' 

canines 
second molars " 



1C 2M 



20 



7th month. 1 

9th " 
15th " 
18th " 
24th " 



3M 2B 



Permanent Teeth.. 
1C 41 1C 2B 



3M 2B 1C 41 1C 2B 

Eruption of anterior molars about 
central incisors ' ' 
lateral incisors " 
anterior bicuspids ' ' 
posterior bicuspids *' 
canines ' ' 

second molars 
third molars (wisdom teeth) about 



3M 



3M 



= 32 



7th year. 

8th " 

9th " 
10th " 
11th <• 
11th " 

12th to 14th year. 
18th to 25th " 



Stomatitis. This inflammation is not limited to the mouth alone, 
but extends to structures within the mouth, as the gums, and may 
invade the tongue. The inflammation is recognized by the subjective 
and objective signs common to such inflammations. There is pain, 
and hence the child (for it usually occurs in children) refuses to nurse 
or take the bottle, or cries when food is given. The pain is accom- 
panied by fcetor of the breath. This occurs in all forms of stomatitis. 
Its origin, as well as the origin of the pain, is readily determined by 
inspection. 

1 Lower incisors first. 



On inspection we note the usual signs of inflammation. They are 
rarely general, being, as a rule, localized to small areas, which may 
rapidly become ulcerated. When general the mucous membrane is red 
and hot ; the color extends to the gums, lips, and tongue. This is seen 
in the catarrhal form ; the follicles are also enlarged. The tongue be- 
comes red and smooth, or may be covered with a white coating, through 
which the prominent red fungiform papilla? project. Accompanying the 
inflammation there is increased secretion, which dribbles from the mouth, 
or is constantly discharged by older patients. The red hue of the mucous 
membrane is attended by swelling. The heat of the mouth is often suffi- 
cient to raise the temperature of the exhaled air, so that the breath is hot. 

A peculiar form of inflammation of the mouth is seen in gouty sub- 
jects. It occurs at intervals. Pain is not so marked, but the heat, 
redness, and burning are associated with a superficial glossitis and sali- 
vation. The saliva is highly acid, and causes a dermatitis on the chin. 
Other mucous membranes are involved at the same time, as the vagina. 
An acid mucoid discharge sets up irritation at the vaginal outlet and 
causes much distress. 

Aphthous Stomatitis. Local areas of intense inflammation are 
sometimes followed by ulceration. Thus in aphthous stomatitis small 
yellowish-white spots appear, at first discrete, but soon dotted over the 
mucous membrane inside of the cheeks, in the roof of the mouth, along 
the sides of the gums, and on the tongue. They subsequently break 
down into shallow ulcers with raised red margins. 

Aphthous ulceration is seen in foot-and-mouth disease. The local 
process is characterized by greater swelling, with softening and ulcera- 
tion of the soft parts, than in other stomatitis. In foot-and-mouth 
disease there is a history of infection, profuse diarrhoea, followed by 
constipation, and considerable physical depression. 

Ulcerative Stomatitis. The disease occurs in ill-nourished sub- 
jects, and is often intercurrent with exhaustive disease, as chronic diar- 
rhoea. It may be seen in epidemic forms in camps and in penal and 
other institutions, on account of unsanitary conditions. In ulcerative 
stomatitis the inflammation is more pronounced on the gums. They 
are swollen, red, and covered with ulcers. The gums in which teeth 
remain are affected, and the ulcers are usually at the gingival border. 
Gums without teeth are not affected. The ulcers are covered with 
yellowish material. The flow of saliva is much increased in this affec- 
tion. It is acid in reaction. The submaxillary glands are enlarged. 
The foetor of the breath is very great. 

Parasitic Stomatitis. Thrush. In parasitic stomatitis, or thrush, 
raised white patches are seen looking like small curds of milk. The 
patches vary in size, and on the tongue may cover an area as large as 
a three-cent piece. (See page 690.) The white patches are distinguished 
from milk-curds because they cannot be removed by the napkin or 
brush. The parasite has been called the o'idium albicans (see Fig. 184) ; 
but Forchheimer prefers to group it under the saccharomyces. 

Stomatitis Materna. Painful ulcers occur in the mucous mem- 
brane of the lips and cheeks in nursing- women. They are solitary, 
and interfere with mastication. 



694 SPECIAL DIAGNOSIS. 

Gangrenous Stomatitis. The affection appears as a gangrenous 
inflammation of the gums, mucous membrane, and deeper tissues of 
the cheek. At first a small, dark red, hard spot is seen, which in- 
creases in size, and becomes of a purplish color. The cheek rapidly be- 
comes swollen, tense, and brawny. On the surface of the more indu- 
rated portions a bleb forms which soon breaks with rapid ulceration. 
The ulcer is dark and gangrenous and soon perforates the cheek. It 
extends to the jaw and is followed by necrosis of that bone/ The 
characteristic odor of gangrene attends the process. While the affec- 
tions previously mentioned are generally dependent upon poor nutri- 
tion, gangrenous stomatitis is always secondary to depraved, depressed, 
or debilitated states of the system. Cases may occur simultaneously 
in asylums for children in which the hygienic conditions are bad and 
the food-supply poor. 

Mercurial Stomatitis. Mercurial stomatitis, or ptyalism, par- 
ticularly affects the gums. It also involves the salivary glands. 
The inflammation is caused by mercury. It may occur from the 
medical use of the drug, particularly in persons who are unduly sus- 
ceptible, or are not particular in regard to mouth-cleansing. The in- 
flammation is painful and attended by profuse discharge of saliva, 
hence the name, salivation. The tongue is swollen, marked on the 
sides by the teeth, and may be protruded with difficulty on account 
of its size. It is tender to the touch. It is covered with a heavy, 
creamy coating. The gums are swollen, red, sore, and bleed on the 
slightest touch. Ulcers along the border occur, may become diffused, 
and in some instances extend to the jaw. The teeth become loosened. 
The foetor of the breath is heavy, offensive, and of a metallic character. 
The inflammation is usually preceded by a metallic taste in the mouth, 
and the patient notices pain on mastication, which increases in severity 
as the inflammation develops. In mild cases it is limited to the gums, 
in others the tongue and salivary glands and the mucous membrane of 
the mouth are affected. 

Leprosy. This affection frequently invades the mouth. The nod- 
ular and ulcerative lesions are seen. It is always associated with the 
characteristic lesions of the skin. Scraping or sections would show 
the characteristic micro-organism. 

Glanders may invade the mouth from the nasopharyngeal space. 

Actinomycosis results from the entrance of the ray-fungus through 
carious teeth or an abraded mucous membrane. Often there is first 
disease of the alveolus, as pyorrhoea, or a periosteal abscess ; then the 
jaw is involved. Before this a general stomatitis may be set up. 

Ulcers. In addition to the above forms of ulcerative stomatitis, 
solitary ulcers are seen in herpes, secondary to gastric or uterine dis- 
turbances, and syphilis. The herpetic ulcers are of frequent occur- 
rence at the menstrual period or during the course of lactation. The 
tendency to their formation is often hereditary. I have seen them 
occur at the menstrual period or in pregnancy in the women of three 
generations. In the secondary stage of syphilis mucous patches are 
seen as bright red, symmetrical, oval, or crescentic patches or erosions, 
occurring on the mucous membrane, sometimes on the tongue and 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 695 

fauces. They are generally covered with a scanty grayish-white secre- 
tion, and are not usually painful. 

Sublingual Ulcer. This form occurs on the frsenum of the tongue. 
It is seen in whooping-cough, and is due to the rubbing of the tongue 
against the teeth in the act of coughing. 

Scleroderma. This rare tropho-neurosis occasionally invades the 
mouth. It is characterized by a submucous infiltration of cartilaginous 
hardness, the surface of which is denuded of epithelium or covered 
with crusts. The invasion comes from the nostrils or the nasopharynx. 
Later the infiltration changes to a yellowish-red or a tendinous-like 
scar. 

The Tongue. 

Examination of the tongue is made for diagnostic purposes with a 
greater show of wisdom on the part of the examiner, and greater satis- 
faction to the patient, but with less satisfactory results from a diag- 
nostic stand-point, than the examination of any other portion of the 
body. The mucous membrane of the tongue is examined because it 
is the only mucous membrane of the body, except the oral and faucial, 
which is open to inspection, and is, therefore, supposed to enable us to 
judge of the effects of general diseases upon mucous membranes. It 
is thought to be indicative of disorders of the gastro-intestinal tract 
because of its relations with it, but recent studies by Hutchinson, 
Butlin, and other observers have resulted in the promulgation of differ- 
ent views. Both the above-mentioned distinguished gentlemen are 
surgeons, and look upon the tongue as a local organ. Investigating 
it as such, they concluded that the changes in the coating, which had 
been considered to have so much clinical significance, depended largely 
upon parasitic invasion, and were not due to changes in the epithelium. 
The parasitic invasion, they hold, is largely dependent upon local con- 
ditions, which, it is true, are on their part dependent upon a state of 
the system. Since the writings of Hutchinson and Butlin, Dickin- 
son returned to the investigation on the lines laid down by older 
teachers, and has, in a measure, restored the tongue to its original 
position as a diagnostic feature in an estimation of the state of the 
general system and in diseases of the gastro-intestinal tract. 

We study the tongue to ascertain its color ; the character of erup- 
tions if they are present ; the occurrence of indentations, excoriations, 
furrows, or fissures ; the occurrence of ulcers and of patches. Plaques, 
nodes, and nodules are also seen on the tongue. Inflammation of the 
tongue occurs, and it is the seat of atrophy and hypertrophy and of the 
various tumors in the parasitic diseases. The movements of the tongue 
are also observed, as an indication of the power of muscles which are 
under centric influence closely related to important centres in the 
medulla oblongata. Surgical affections of the tongue will not be con- 
sidered ; local affections will only be referred to in connection with 
general diseases. 

Discolorations of the Tongue. Yellowish-white, oblong patches, 
soft, but slightly raised, are sometimes seen along the sides of the 
tongue — xanthelasma. They are sharply defined, and vary in size from 



696 SPECIAL DIAGNOSIS. 

a split pea to a three-cent piece. Xanthelasma is also situated upon 
the eyelids and upon the palms of the hands, rarely in other portions 
of the body. It occurs in jaundice, or in persons who are said to be 
subject to bilious attacks. 

Pigmentations. Dark purple, bluish-black, or black marks are 
seen on the tongue as well as on the surface of the lips, where they 
may be brown. They are sharply defined, neither raised nor de- 
pressed, and vary in size. Such pigmented spots are seen after glos- 
sitis and in Addison's disease. In the latter affection other pigmented 
areas are found. Bloodstains are observed in purpura. Bright red 
spots the size of a split pea or larger, patches, known as ecchymoses, 
are of frequent occurrence. They are not removed by pressure. 
Hemorrhagic infarcts are sometimes seen on the tip of the tongue. 

Black Tongue. This rare condition is of parasitic origin. It has 
recently been described anew by Cohen. It is also known as nigrities. 

The affected portion is of a brownish-black or black color, varying 
in size and usually situated in the middle of the dorsum of the tongue. 
It looks like an iron- stain, and in some instances the surface is rough- 
ened. The papillae are abnormally enlarged. It usually begins as a 
small spot, and extends slowly, so that at the end of a month the 
dorsum is covered. The centre is blacker than the circumference. 
After the entire dorsum is covered the spot begins to disappear from 
the circumference toward the centre, and is followed by desquamation. 
This series of phenomena is repeated and the entire affection subsides 
slowly. Desquamation may last from a few days to two months. The 
papilla? of the affected surface, too, look like " a field of corn laid by 
the wind and rain." The sensations of taste and touch are not altered, 
but a feeling of dryness is marked. It must be remembered that 
a black tongue is sometimes the result of deliberate deception. 

Inflammation of the Tongue. Acute glossitis is a rare affection, 
more common in adults than in children, and more frequent in men than 
in women. It occurs more frequently in the summer. The onset is rapid. 
After a short period of tenderness on mastication the movements of the 
tongue are stiff and painful, or there are pains in the muscles of the neck 
and submaxillary region. In a few hours the tongue swells. It rapidly 
increases, and at the end of fifteen to twenty hours is three times its 
natural size, protrudes from the. mouth, is indented by the teeth, and 
is almost immovable, feeling heavy, painful, and tender. It is coated 
with a thick fur on the dorsum. Salivation accompanies these symp- 
toms, speech is impossible, dysphagia extreme, and dyspnoea not un- 
usual. The glands underneath the jaw are swollen. The temperature 
rises to 101°, rarely above it, even if the case is severe. Death may 
occur in a few hours from suffocation, or after a longer interval from 
diffuse suppuration, gangrene, exhausting septic fever, or pneumonia. 
Gangrene is more frequent than spontaneous resolution. If resolution 
is to be established, the swelling begins to subside in three or four 
days. Small ulcers form on the surface of the tongue, and by the end 
of a week its normal appearance is regained. The fever and distress- 
ing symptoms subside with the local swelling. It is said to be due to 
colds, to bites and stings of animals, to mercury, and to corrosive and 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 697 

acrid substances. It may occur in fevers. The diagnosis is easy. It 
must be distinguished from acute oedematous swelling due to salivary 
calculus or affections of the floor of the mouth. Acute ranula some- 
times causes considerable swelling of the tongue, simulating acute 
glossitis. Hemiglossitis sometimes occurs. The local symptoms are 
not so great, because only half of the mouth is occluded. I saw a case 
in which the inflammation was limited to half the side of the tongue 
on the posterior surface. It went on to suppuration, but was not 
attended by serious symptoms, except discomfort in eating. It was 
preceded by a definite nodule in the substance of the inflamed part. 
Glossitis from mercurial poisoning has been described in connection 
with stomatitis. 

Chronic superficial inflammation of the tongue may also occur. The 
surface is smooth and deprived of papillae over the affected area, which 
is redder than natural. The margin of the raw patch is sharply de- 
fined, but the area has no depth. The epidermis alone is removed. 
When associated with dyspepsia it covers a considerable area of the 
surface of the tongue. The tongue may be deprived of papillae on the 
anterior part of the dorsum while the fungiform papillae remain. The 
tongue is enlarged and the borders marked by the teeth. The surface 
looks glossy. The tongue feels stiff and uncomfortable. Movement is 
irksome, irritating foods are painful. Spirits and tobacco cause dis- 
tress. Indiscretions in diet and slight traumatism quickly produce 
fresh inflammation. One observer, Hack, has described a form of 
glossitis hereditary and peculiar to women. He observed a row of long, 
oval areas, caused by previous inflammation. They commenced in early 
childhood. The tongue was smooth over remaining large areas, with 
red excoriations here and there. There was no syphilis. 

Sequelce of glossitis. Indentations occur when the tongue is swollen, 
as in mercurial and other forms of glossitis. The borders of the tongue 
are indented by the pressure of the teeth. But in states of debility 
a flabby tongue with indented borders is often seen. Sometimes the 
swelling is so great that the pressure of the teeth causes ulceration. 

Furroivs, or grooves and tvrinkles, are seen on the dorsal aspect 
of the tongue. They are not necessarily tokens of disease ; in many 
persons they are of constant occurrence. Furroivs vary from a few 
lines to an inch or more in length. . In many this is most striking in 
the middle line of the tongue. The median furrow is liable to become 
ulcerated on slight provocation. The edges of the fissures are smooth 
and without papillae or fur. Other furrows are directed horizontally 
and vary in depth. They may be curved and forked. They are more 
frequent in older persons, especially if the tongue is too large to lie 
within the circle of the teeth. They are an evidence of past inflamma- 
tion, or rarely of hypertrophy. They resemble the median furrows as 
regards smoothness and absence of fur. Inflammatory furrows occur 
in chronic superficial inflammation, but more commonly after chronic 
inflammation which has left the tongue enlarged. The furrows are 
sometimes so abundant that the surface of the tongue looks like the 
eyelid. The raised areas become sore, due to irritation of a foreign 
body (food) or a tooth. They are an indirect result of inflammation. 



698 SPECIAL DIAGNOSIS. 

True inflammatory furrows, described as dissecting glossitis by Wun- 
derlich, occur. Dissecting glossitis is only a more aggravated form of 
superficial glossitis. Furrows of this character may be due to syph- 
ilis, and dissecting glossitis sometimes has a syphilitic origin. Fissures 
and clefts are frequently caused by the rubbing and deep indentation 
of a rough and jagged tooth. The area around the fissure is inflamed 
and its base indurated. The sides and bottom are ulcerated. It is 
recognized by its relation with the offending tooth. It may be mis- 
taken for syphilis, another common cause of fissures. 

Syphilitic Lesions. It must be remembered that the tongue is 
always predisposed to inflame and ulcerate in syphilis. In secondary 
syphilis fissures are always found on the borders of the tongue ; they 
are almost certain to occur if the teeth irritate the border. They may 
be due to the ulceration of a mucous tubercle which is developed upon 
the border of the tongue. The ulcer is stellate, and gradually deepens 
until it becomes a foul fissure. Two processes cause the ulceration — 
the specific infection and the irritation of the teeth. Syphilitic ulcers 
are not very angry, as are non-syphilitic sores and fissures which may 
occur in persons in poor health. They may be sensitive, however, on 
account of the involvement of the tongue. The absence of active in- 
flammation, the large number of sores and fissures, and the associa- 
tion with other lesions of the disease upon the tongue, cheeks, and lips 
point to their syphilitic origin. Tertiary syphilitic ulcers are more 
pronounced and deeper than other forms. They may be as long as 
two or three inches ; they are sinuous and branched. Gummata may 
occur on the tongue at the same time. The gummata may be circum- 
scribed or linear, and may break down and ulcerate. Sclerosis of the 
tongue, as described by Fournier, follows the healing of these ulcers. 
It is curious to note that the lymphatic glands are seldom enlarged in 
association with syphilitic fissures. The fissures must be distinguished 
from carcinoma and tuberculosis. In carcinoma there is a distinct 
tumor, which may become fissured. Tuberculous ulceration is a sign 
of the presence of tubercle in other organs. The tuberculous fissures 
are small, at first single ; tubercle, however, rarely begins as a fissure, 
but as tuberculous ulcers on the tip or borders of the tongue. They 
are stellate or irregularly branched. They are shallow at first, and 
deepen later, but do not widen in a corresponding manner. The 
lymphatic glands are always involved. (See Tuberculous Ulcer.) 

Ulcers of the Tongue. They may be simple, aphthous, or trau- 
matic. Simple ulcers follow long-standing superficial glossitis. They 
form in the centre of the tongue, or of the inflammatory area. 
They are due to sloughing, or simple melting away of epithelium. 
The ulcer is smooth, red, glazed on the surface. The edges are callous 
and inactive, and the shape irregular. It is sensitive, and may be pain- 
ful. The signs of chronic glossitis continue with it. Dyspeptic or 
catarrhal ulcers occur on the tip, or on the dorsum near the tip. The 
dorsum of the tongue, from the tip backward, is very red, and filiform 
papillae are absent. The ulcers are small and superficial without defi- 
nite shape or character, except that they are red and irritable. Dys- 
peptic ulcers may occur from the breaking down of vesicles on the 



DISEASES OF MOUTH, FAUCES, PHARYNX, CESOPHAGUS. 699 

tongue. They are small, circular, well-defined ulcers, with sharp-cut 
edges, in size from a pin's head to a split pea, and are the source of 
considerable pain and much annoyance. They are recurrent. Saliva- 
tion may attend them. Aphthous ulcers are seen in children and adults, 
and when multiple are attended with the same symptoms as aphthous 
ulcers of the mouth, with slight fever. Foetor is characteristic. When 
single they occur with indigestion, or in women at the menstrual period. 
The tendency to their formation is inherited. Traumatic ulcers from 
sharp teeth may persist a long time if the general health is bad. When 
indolent they may be mistaken for syphilitic, tuberculous, or cancer- 
ous ulcers. The rapidity of formation, the location opposite a rough 
tooth, and the absence of other signs of syphilis point to the true 
nature of the ulcer. Chancre can be excluded by the greater hard- 
ness and circumscription of the lesion, its seat near the tip, and its 
association with enlargement of the lymphatic glands. The latter is 
not present in traumatic ulcer, unless it is acute and angry. Traumatic 
ulcer is distinguished from tuberculous ulcers by the absence of signs 
of tubercle in other organs and by the result of an examination of the 
scrapings of the ulcer ; from cancer by the age. In cancer all the 
glands become affected later. 

Excoriations on the surface of the tongue, or rawness, arise from 
injury, and may also be seen in dyspepsia. 

Tuberculous Ulcer. The tuberculous ulcer presents an uneven, 
pale, flabby surface, covered with a yellowish-gray viscid or coagulated 
mucus. The edges are sometimes sharp-cut, sometimes bevelled, 
seldom elevated. They are not usually very red. There is but little 
surrounding inflammation, and the adjacent portions of the tongue are 
but slightly swollen. The borders of the ulcer may be sinuous, and 
the shape oval or ovoid, or elongated. In the neighborhood of an 
ulcer a number of tiny yellowish gray points may be observed. The 
ulcer is painful, and attended by salivation. I saw in the Philadelphia 
Hospital a case of tuberculous ulcer of the tongue, in a young man 
twenty-five years of age, with pulmonary and intestinal tuberculosis. 
The dorsum of the tongue was covered with a dozen ulcers, with sharp- 
cut edges and pale, flabby granulations, without induration or inflam- 
mation around them. They were yellowish-gray, and tubercle bacilli 
were found in the scrapings. Tuberculous ulceration must always be 
carefully distinguished from syphilitic and cancerous. The associate 
symptoms are often most reliable. Ulcers due to lupus are also seen 
upon the tongue. 

Patches and Plaques. Space forbids further consideration than 
the naming of the plaques which are seen on the tongue. First, there 
is the smoker's patch, on the middle of the dorsum about the point 
where the tobacco-pipe rests, or where the stream of smoke from the 
pipe or cigar strikes the tongue. This is a slightly raised area of oval 
shape. It is not ulcerated, but is smooth and red, or livid. Some- 
times it is bluish-white or pearly in appearance. The smoothness is 
characteristic. White and bluish-Avhite patches or plaques are seen in 
leucoma, leucoplakia, ichthyosis, keratosis, and are also known as opaline 
plaques. The smoker's patch belongs to the same class, and is proba- 



700 SPECIAL DIAGNOSIS. 

bly an early stage of these affections. It is a whiteness, or white 
opacity of the surface of the tongue, usually on the dorsum. It is 
almost always the result of the direct action of irritants. These patches 
are unknown under twenty years of age, do not commence after sixty, 
and very rarely attack women. They are not attended by subjective 
symptoms usually. There may be a sensation of induration and dry- 
ness. The course is always chronic. 

Wandering Rash. Ringworm, or circular exfoliations — the geo- 
graphical tongue — occurs most frequently in children. One or more 
patches on the dorsum of the tongue are observed, smooth and red, 
but not depressed or elevated. The filiform papilla? have been shed. 
The patch spreads and becomes a ring, circular or oval. The border 
is faintly or decidedly yellow, and usually slightly raised and sharply 
defined. The circles may widen and contract from time to time. No 
subjective symptoms are noted except itching in a few cases. The 
cause is not known. The diagnosis is easy. It may continue for 
months or years. 

Mucous patches are multiple lesions of syphilis in the mucous 
membrane. They have been referred to in the section on Diseases of 
the Mouth. 

Eruptions. Eruptions of variola, measles, and erysipelas are seen 
on the tongue. Herpes and aphthous ulcers, preceded by vesicles, are 
met with on the surface of the tongue. 

Nodes. Nodules in the tongue are always tuberculous or syphilitic. 

Atrophy. Atrophy of the tongue is very unusual. Hemiatrophy 
may occur as the effect of central or peripheral causes, as softening, 
hemorrhage, or tumors of the region of the hypoglossal nucleus. Other 
centres near the nucleus are affected, hence other forms of paralysis are 
seen, due to the lesions of the medulla. These are seen in progressive 
muscular atrophy and bulbar paralysis, and in cases of hemiplegia. 
It is not difficult to recognize it on inspection. The functions of the 
tongue are not affected. 

Hypertrophy. Enlargement of the tongue, or macroglossia, is gen- 
erally congenital, but may occur late in life. The tongue enlarges, and 
is accompanied by pressure symptoms due to such enlargement. 
Hypertrophy of the tongue is sometimes seen in idiots and cretins. 
The hypertrophy is more frequently the result of lymphatic obstruc- 
tion, on account of which there is lymph-stasis. The diagnosis is easy. 
Inflammatory hypertrophy occurs in stomatitis, and syphilitic hyper- 
trophy occurs with gummata. 

Cysts. Various cysts occur in the tongue. Mucous cysts and 
blood-cysts are the most common. The cysticercus cellulosse and the 
echinococcus occur rarely. Ranula is a cyst underneath the tongue 
that causes suffering from mechanical obstruction. It is easy of recog- 
nition. 

Parasitic Disease. Thrush is the most common. Other infections 
of the mouth extend to the tongue in most instances. 

The Tongue in General and Remote Disease. The Coating. 
With a view to estimate the condition of the system in general by 
the appearances of the tongue, excluding all local conditions, the 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 701 

following characteristics are observed : First, the color ; second, 
the fur ; third, the degree of moisture ; and, fourth, the movements. 
The student should bear in mind that changes in the condition of 
the tongue are frequently of local origin ; that dryness, for in- 
stance, may be due to the open mouth, or that a coating may be 
unusually marked because the tongue had not been used in mastica- 
tion. Often coating is seen on one side of the tongue. This has been 
referred to as due to disease of the nerves of one side. It is just as 
likely to be due to an absence of mastication on that side of the mouth, 
the bolus of food being kept on the other side because of pain, diseased 
teeth, or other local cause. 

Clinical experience has shown that certain conditions in the tongue 
are associated with certain general conditions which render the appear- 
ance somewhat diagnostic. The term diagnostic must be qualified, 
because the changes are so often local, or are modified by conditions 
independent of the general system. For convenience, the classification 
of Dickinson as to the appearance of the tongue in disease may be 
utilized. In the Lumleian lectures this eminent authority described 
the average healthy tongue based on extensive observations. Depart- 
ures from the normal were arranged and afterward classified. It re- 
sulted in the formation of eleven classes : 

1. The Stippled oe Dotted Tongue. The tongue is moist and 
dotted with little white points, due to an excess of white epithelium 
on the papilla?. It is usually seen hi persons in poor health without 
fever. It is not, therefore, a febrile tongue, nor one indicative of 
grave constitutional disease. It is seen in cases of chronic disease, 
usually one in which there are no grave symptoms. 

2. The Dry Stippled Tongue. This is found in mildly acute dis- 
eases, or in cases in which the constitutional disturbance is more marked. 

3. The Stippled and Coated Tongue. The patients in whom 
this is found are very frequently the subjects of acute and constitu- 
tional affections. Fever is more frequently present with this variety 
of fur. 

4. The Coated Tongue. There is excess of white epithelium on 
the papilla?, and the coat is continuous. The intervals between the 
papilla? are more commonly filled up with epithelium and accidental 
matters than in the preceding types. It is seen in acute and febrile 
diseases, and whether moist or dry, in pneumonia, pleurisy, and typhoid 
fever. It is associated with a far greater degree of prostration and 
pyrexia, while the saliva is absent in the larger proportion of cases. 

5. The Strawberry-tongue. The tongue is coated and injected ; 
the fungiform papilla? shine through the coat, particularly at the tip 
and edges. It is the tongue of scarlet fever, but may often be seen in 
any acute febrile disorder. In scarlet fever, however, it appears by 
the second or third day — most marked after the second. Pyrexia is 
more common in this class than in the preceding. 

6. The Plaster-tongue. A thick, uniform coat, edges abrupt 
and striking, covers the tongue. The papilla? are elongated and the 
intervals crowded with accumulations, among which are bacteria ; it 
is the tongue of acute febrile disease. Fever was marked in a number 



702 SPECIAL DIAGNOSIS. 

of cases Dickinson studied, and prostration was a common attendant. 
Saliva Avas deficient. 

It is thus seen that, beginning with the healthy tongue, Dickinson 
described a series of groups, in each succeeding one the coating becom- 
ing more marked, with or without moisture. The clinical association 
that he found is a common experience. Each successive group was 
attended by more fever, greater exhaustion, and less saliva than the 
preceding group, and in each the tongue became more and more furred. 

7. The Furred or Shaggy Tongue. When moist the papillae 
are greatly elongated, composed mostly of horny epithelium. It has 
the same appearance as if the tongue were dry. The moist, furred 
tongue is not so common as the other. It is most commonly seen in 
old age and in constipation. The dry, furred, or shaggy tongue may 
succeed the dotted tongue or the coated tongue in the course of ad- 
vancing disease. It is the result of disease and want of moisture. 
The saliva is deficient ; it indicates that there has been fever, and that 
possibly but little food was taken. 

8. The Incrusted, Dry Brown Tongue. Over the surface of 
the tongue there is a dry, thick, felted coat, which is continuous and 
dips down betAveen the papillae. The coat is largely made up of para- 
sitic material. In the course of fevers it is the outcome of a preceding 
condition, the coated tongue, and is indicative of the typhoid state. It 
occurs in the fevers with high temperature, but may be seen in condi- 
tions of Ioav temperature, as from cancer, phthisis, albuminuria, chronic 
nervous diseases. There is much depression or prostration associated 
with it, and there is absence of saliva. If the patients with a dry 
brown tongue recover, it retrogresses to the furred or incrusted tongue, 
which in turn becomes bare gradually, at first in small layers ; the latter 
is thin, usually dry, but is more moist than the dry broAvn tongue. 
As the incrustation disappears it may become bare, red, and dry. 

9. The red dry tongue indicates a more serious condition usually 
than the dry and broAvn. It is the tongue of chronic wasting diseases. 
It occurs in phthisis in the later stages, and, as the raw-beef tongue, is 
associated with dysentery and also with liver abscess. There may be 
fever associated Avith the cases. It is in a measure the tongue of 
chronic diarrhoea. The tongue is shrunken, red, polished, and smooth. 
The papillae have disappeared and the epithelium is stripped off in 
patches. It may be associated with aphthae. If the patient is to im- 
prove, the redness fades, the papillae become softer, and the moisture 
returns. 

10. Red and Membranous ; otherwise as (9) the red denuded 
tongue. 

11. Cyanosis, or Venous Congestion of the Tongue. The 
tongue is of a bluish or purplish color, the surface is smooth and Avet, 
and the papillae are almost indistinguishable. It is not confined to 
organic heart disease or cyanosis. It is of quite frequent occurrence 
in albuminuria. With the venous congestion in the albuminuric cases 
there is always a superabundance of deep epithelium. When the sur- 
afce is examined it looks as if the papillae Avere fused together and 
overlaid by a moderate coat. 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 703 



Classification of Tongues. 



To the naked eye. 
1. Healthy, moist. 


Microscopically. 

White epithelium in small amount on papillae, not 
continuous or superabundant. 


2. Stippled, moist, dotted with 

white. 
2(D). 1 Stippled, dry. 


Excess of white epithelium on papillae, not extend- 
ing between them. 
Ditto. 


3. Stippled + coated ; moist. 
Coat continuous in parts. 


White epithelium on papillae in excess, with partial 
filling of intervals. 


4. Coated white ; moist. Coat 
continuous. 

4(D). Coated white, dry. Coat 
continuous. 


Excess of white epithelium in papillae. Intervals 
more or less filled up with epithelium and acci- 
dental matter. 

Ditto. 


5. Strawberry, coated -(-injected, 
especially showing in fungi- 
form papillae. 


Like the coated or plastered, but with more injec- 
tion. 


6. White, plastered, thick, uni- 
form coat ; edges abrupt and 
striking. 


More elongation of papillae than with coated 
tongue, more filling of intervals with superficial 
accumulation. 


7. Furred or shaggy, moist. 

Greatly elongated papilla 3 . 

7 (D). Furred or shaggy, dry. 


Extravagantly Ion? papillae, mostly of horny epi- 
thelium. 
Ditto. 


8. Incrusted, dry, brown ; thick, 
felted dry coat over papilla?. 


Continuous crust on and between papillae, largely 
of parasitic matters. 


9. Furred or incrusted, becom- 
ing bare. Generally dry. 


Crust breaking away, together with more or less of 
normal surface. 


10. Eed, denuded. Absence of 
normal covering. 


General absence of all epithelium excepting the 
Malpighian layer ; sometimes of that also. 


11. Red, smooth, dry, membranous 
covering. 


Level membrane replacing epithelial processes. 


12. Cyanosed. 


Injected; hypernucleated ; excess of deep epithe- 
lium. 



Moisture of the Tongue. The moisture is due to the saliva, 
any deficiency of which causes dryness of the tongue. It is natural, 
therefore, to conclude that any changes in the moisture of the tongue 
are due to altered secretion of the salivary glands. This is almost 
ahvays deficient when fever is present, and hence the tongue is dry. 



1 The letter D is used to imply dryness. Thus, to Class 2 a certain description is 
attached. Class 2 D presents the same characteristics with the addition of dryness. 



704 SPECIAL DIAGNOSIS. 

At tlie same time, it must be remembered that this failure of secretion 
of the salivary glands does not depend upon gastro-intestmal disturb- 
ance. 

Dryness of the tongue, it must not be forgotten, may be due to in- 
crease of evaporation from keeping the mouth open, as well as to 
diminution of the salivary secretion. All states, therefore, in which 
the mouth is open will lead to dryness of the tongue. Again, in 
chronic fever, dryness of the tongue is a constant characteristic. 
Dryness is due to the effects of the temperature upon the secretions 
in general, but it is not the effect of high temperature, curiously, 
but rather a temperature which has persisted for a considerable 
length of time. Thus, in pneumonia, with a temperature of 105°, 
the tongue may be moist ; whereas, in typhoid fever, with a tem- 
perature of 103°, the tongue is dry. General dehydration of the 
body causes dryness of the tongue, even without local diminution of 
secretion. This dehydration is seen in diarrhoea, in which disease 
simple or uncomplicated dryness of the tongue is the common symp- 
tom. It is curious to observe that in cholera the tongue remains moist 
even until death ; whereas, if the patient is about to improve and the 
discharges cease, reaction and fever setting in, the tongue begins to dry 
and becomes quite brown. Local causes may explain this. The watery 
vomit may keep the tongue moist, and the temperature of the body 
may contribute to the change. Next after diarrhoea we have excessive 
discharge of urine as a frequent cause of dryness. Hence, in diabetes 
in all forms extreme dryness of the tongue is seen. The osmotic action 
of the sugar in the blood is the cause of a reaction in diabetes mellitus, 
just as it is in cases of dehydration of the lens in cataract. The final 
cause of dryness of the tongue is prostration. Asthenia in all forms 
continuing over a moderate period of time, as a week or ten days, 
causes lingual dryness. 

The Effects of Food. These must be studied before deciding 
upon the clinical significance of changes in the tongue. The immedi- 
ate results of taking of food influence the coating and the degree of 
moisture. The act of eating cleanses the tongue. In disease, there- 
fore, in which this act is not performed, it is natural that we observe 
more fur on the surface, and in conditions in which diet is limited to 
fluids the effect is marked. In cases of liquid diet the tongue is likely 
to remain furred. It is particularly seen in patients who are kept 
upon a milk-diet exclusively. 

The Tongue in Relation to Diseases of the Alimentary Canal. 
So much has been written on this subject that it is well to give the 
experience of Dickinson briefly. He has not been able to discern 
any relationship between any state of the tongue and dyspepsia, or 
ulcer of the stomach, apart from that which might occur from loss of 
appetite or restriction in the amount of food. With regard to the 
bow els, some forms of constipation are often connected with changes 
in the tongue, but such connection is not constant. The author rather 
tli inks it to have been a coincidence, and cannot even point to the 
diagnostic significance of the tongue in obstruction. The state of the 
tongue in the latter condition is dependent not upon the intestinal 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 705 

lesion but upon the constitutional disturbance. A dry tongue is well 
known to occur in acute obstruction, due to deficiency of salivary 
secretion. In chronic obstruction, unless, however, there is consti- 
tutional disturbance, the tongue will not change. In diarrhoea all con- 
ditions of dryness, furring, and incrustation are observed. The 
absence of saliva, dehydration, and pyrexia help the desiccation. In 
diarrhoea and dysentery, therefore, the change in the appearance of 
the tongue is more marked than in any other disease. 

Other Diseases. As regards the relation of the tongue to other 
individual diseases but little can be said. Of more direct association, 
we have the cyanotic tongue in heart disease ; the dry tongue in 
chronic albuminuria and diabetes mellitus ; the strawberry-tongue of 
scarlet fever ; and the dry brown tongue of typhoid fever. Of course, 
the so-called typhoid tongue represents but one stage of typhoid fever. 
Throughout the disease it may present all varieties in direct succes- 
sion, from the stippled, the coated, the plastered, the furred, to the 
incrusted. In lobar pneumonia the same changes occur as the disease 
advances. In bronchitis the lower degrees of coating are presented, 
while in rheumatism the variety is considerable. In conclusion, it 
may be stated that the tongue seldom points to solitary organs or iso- 
lated disorders, but is a gauge of the effects of disease upon the system. 

The Tongue in Prognosis and Treatment. Clinical observers 
agree with Dickinson, that the condition of the tongue is due very 
largely to the four states with which he has associated it — dehydra- 
tion, exhaustion, pyrexia, and local conditions about the mouth. As 
these conditions modify the state of the tongue, it is evident that the 
first sign of improvement, as return of moisture, denotes a diminution 
in temperature. Its appearance is, therefore, of good prognostic omen. 
The degree of fever, the state of the nervous system, the maintenance 
or abeyance of secretions, and the failure of vitality, are indicated by the 
condition of the tongue. The return of moisture, the removal of fur, the 
subsidence of tremor, at once indicate that the patient is getting better. 
The persistence and increase of these signs show that the disease is get- 
ting the better of the patient. As to indications for treatment, the dry- 
ness, furring, and incrustation are connected with the want of saliva. 
The processes by which this want is brought about differ. They have 
previously been referred to, and the indications for treatment are obvious. 
One can infer from the state of the saliva the condition of the intesti- 
nal canal, a matter of the highest importance practically. There is no 
doubt that, except possibly in diabetes, when there is diminished 
saliva, there is also diminished gastro-intestinal secretion. Such 
diminution is followed by loss of appetite and impairment of digestion. 
The indication is at once to administer material that is digested with 
the least difficulty. Hence, liquid food and stimulants are to be used. 
The dry and bare tongue is of serious prognostic omen in all conditions. 
While it may be due to want of saliva alone, it also occurs as a part 
of the failure of nutrition in hectic fever, suppuration, and other condi- 
tions. It is an indication for the use of tonics, stimulants, and liquid 
and highly nutritious food. The weak pulse does not more surely tell 
of an asthenic tendency than the red, dry, and polished tongue. 

45 



706 SPECIAL DIAGNOSIS. 

Movements of the Tongue When the patient is asked to put out 
his tongue it is done without other movement than that required for 
its ejection. Interference with its motility occurs in disease, when the 
projection is attended by abnormal movement. It may be tremulous, 
as in alcoholism or in simple weakness alone. It may be slow or im- 
peded in the various stages of paralyses. It is tremulous and the seat 
of fibrillar contractions in general paralysis. It cannot be projected 
at all in glosso-labial paralysis ; it can be projected, but with difficulty, 
and may have to be aided by the finger, in general paralysis and diph- 
theritic paralysis, progressive muscular atrophy, and hemiplegia, be- 
cause the paralysis is only partial. The tongue points to the paralyzed 
side of the body in hemiplegia when the face is involved. 

Angina Ludovici. Angina Ludovici is characterized by slight 
inflammatory congestion of the throat out of proportion to the symptoms 
of the inflammation in the external structures. Woodeny induration 
of the connective tissue, which will not pit on pressure ; spreading of 
this induration, which is circumscribed, so that it is bound sharply by 
unaffected cellular tissue, is characteristic. The induration may extend 
from the rami of the jaws to the face. With this there is a hard swell- 
ing in the tongue and along the lower jaw, causing thickening of the 
floor of the mouth. This is observed by palpation with the finger in 
the mouth. The glands are not affected. For a long time the nature 
of this affection was not known. It is now believed to be due to 
actinomyces. (See Parker, Lancet, 1879, and Anderson, Transactions of 
the Medico-Chirurgical Society, 1891.) 

The Fauces and Pharynx 

The passageway between the mouth and the respiratory passages is 
lined with mucous membrane, which is subject to diseases to which 
they are liable. The symptoms thereof are similar to the symptoms 
of mucous membrane inflammation elsewhere. The large muscles of 
the pharynx which aid in deglutition are subject to affections which 
belong to muscular tissue generally, hence rheumatic inflammation and 
loss of power of muscle, or paralysis occurs. Paralysis of the pharynx 
has not the same practical importance in diagnosis of central lesions as 
paralysis of other structures, such as parts of the larynx. This is due to 
the fact that the nerve-supply of the pharynx is derived from a nerve 
(glosso-pharyngeal) which supplies other structures, paralysis of which 
is more evident than pharyngeal paralysis, more readily ascertained, 
and which causes more pronounced symptoms. (See Cerebral Nerves.) 
From its exposed situation the pharynx is particularly liable to infec- 
tion from micro-organisms. The infection may extend from the mouth, 
or from the nares above, or the micro-organisms may affect it primarily. 

The fauces and pharynx may be the seat of morbid processes which 
occur secondarily to diseases in other portions of the body with a mod- 
erate degree of frequency. Inflammations of the mucous membrane 
of the pharynx are of rheumatic or gouty origin in a large number 
of cases. Indeed, gouty inflammation of the pharynx seems to be 
more common than gouty inflammations of mucous membranes in other 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 707 

situations. The large majority of subacute or chronic pharyngeal in- 
flammations are secondary to dyspepsia. They also occur from exten- 
sion of the disease from cavities related to the pharynx. 

Affections of the tonsils are usually more common in rheumatic 
states, and bear some relationship to the rheumatic diathesis. Inflam- 
mation of the tonsils may follow acute rheumatism or may alternate 
with it. A patient who is predisposed to rheumatism may at one 
season have tonsillar inflammation, at another rheumatism. The 
writer has seen tonsillitis immediately followed by rheumatism, and 
then the latter replaced by the former. 

Apart from what has just been said, diseases of the pharynx bear 
but little, if any, diagnostic relationship to disease elsewhere. While 
there may be cyanosis of the mucous membrane, or tuberculous ulcer- 
ation, or other changes which we have noted, the signs of the primary 
disease are so much more marked that we need not rely upon the 
appearance of the pharynx or symptoms of pharyngeal disease for 
diagnostic purposes. The only general affection which may be diag- 
nosticated from the appearance of the pharynx alone is measles. In 
obscure cases of sudden fever, with nasal catarrh, the appearance of 
the eruption in the situation just indicated may lead to the recogni- 
tion of measles when the external eruption is not apparent. For 
the purposes of the therapeutist it should be borne in mind that symp- 
toms referable to the pharynx are very frequently due to disease in 
the nares, particularly in that portion of the pharynx which is not 
open to direct inspection — the nasopharynx. 

The general symptoms of pharyngeal disease are not marked, except 
in diphtheria, in erysipelas, in retropharyngeal abscess, and in affec- 
tions of the tonsils. In the latter the general symptoms appear to be out 
of proportion to the local process. The high fever, the intense head- 
ache and backache, and rapid pulse, seem to point to a process which in 
extent and severity should far surpass that which occurs in the tonsils. 

As a passageway or channel, affections of the pharynx are liable to 
obstruct it, causing symptoms of occlusion. As a channel for the pas- 
sage of air, obstruction in the pharynx will lead to dyspnoea. In addi- 
tion to its function as a simple channel, the pharynx is concerned in 
the act of deglutition. When, therefore, there is obstruction of the 
pharynx, deglutition is made difficult, or may even become impossible. 

Attention cannot be too strongly directed to the investigation of the 
nasopharynx in children who are poorly developed physically and men- 
tally, and who present appearances that, to the practised eye, are most 
familiar. The experienced observer will at once judge, and judge cor- 
rectly, that this combination of symptoms is due to disease in the naso- 
pharynx. Reference must be made to the remarks on adenoid vegeta- 
tions of the nasopharynx, but it is proper to state here the relationship 
and the importance of investigating the structures in the class of cases 
just indicated. 

The Data Obtained by Inquiry. 

Pain. In affections of the fauces and pharynx pain is one of the 
most common subjective symptoms. It is due to the fact that the 



708 SPECIAL DIAGNOSIS. 

functional acts of the pharynx require movement of all the struc- 
tures. When they are the seat of inflammation, or ulceration, the 
movement excites pain. It is, therefore, a symptom of great severity 
in inflammation of the tonsils and pharynx, of rheumatism of 
the muscular structure of the pharynx, and of tuberculous and can- 
cerous ulceration. Pain hi the pharynx is a frequent accompaniment 
of post-nasal inflammations, although the pharynx itself is not 
affected. 

Dryness. Dryness of the fauces, with a tickling sensation and a 
more or less constant desire to hawk, occurs in pharyngitis. Hawk- 
ing, however, is not a symptom of disease of the pharynx alone. It 
may also be due to disease in the posterior nares. 

The Odor of the Breath. In follicular tonsillitis the breath has 
a peculiar odor. This is more marked in the milder forms of inflam- 
mation, with retention of the secretion of the glands. The odor is in- 
tense and foetid. In cancer and syphilis there is also foetor of the 
breath. The foetor may be of diagnostic significance in distinguishing 
cancer from tuberculosis. 

Dysphagia. The symptom varies in degree from slight difficulty 
in swallowing to complete prevention of the act. Any disease which 
occludes the passageway causes dysphagia ; pain is also a cause. It 
is, therefore, present in all painful affections of the pharynx. Dysp- 
noea is seen in tumors, hi inflammation of the tonsils, in the rare form 
of erysipelas of the pharynx, and in retropharyngeal abscess. It 
occurs from occlusion of the passages, and is more marked in retro- 
pharyngeal abscess and erysipelas than in other conditions. In cer- 
tain forms of abscess of the tonsils it may be very extreme. 

Spasm of the pharynx is a subjective symptom complained of in some 
cases of pharyngitis. The degree of spasm or the amount of choking 
sensation is largely dependent upon the neurotic constitution of the 
individual. It may be extreme when only a moderate amount of inflam- 
mation is present. It is seen in the most aggravated form in hydrophobia. 

The Data Obtained by Observation. 

Examination of the Fauces. Method. For this purpose examin- 
ation is made by the unaided eye, illuminating the throat as in the ex- 
amination of the larynx. The difficulties of examination arise from the 
tongue and the uvula. The mouth should be opened as wide as is con- 
sistent with comfort and in an unrestrained manner. The tongue is 
pressed out of the way by the use of a tongue-depressor. In many cases, 
however, even with the tongue-depressor, the tongue muscles will con- 
tract and the organ bunch up in the mouth. Moderate, quiet, full 
breathing, gently opening the mouth as the deeper inspirations are made, 
causes the tongue to relax and lie in the bottom of the mouth, and at 
the same time elevates the uvula. At the time of a full breath the 
part may be inspected throughout. Sometimes the fauces can be ex- 
amined if the tongue is protruded and held with a soft napkin between 
the finger and thumb by the patient. In the fauces the tonsils and 
uvula are to be observed, following out the routine method of ascer- 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 709 

taming all facts. Attention is then paid to the posterior wall of the 
pharynx, with the same object in view. 

Inspection. In examining the fauces and pharynx observation is 
made of the color of the parts, the appearance of the mucous mem- 
brane and its glands, the appearance and position of the uvula, the 
size of the tonsils, the character of the secretions on the pharynx, and 
the presence or absence of swellings and abnormal exudations. 

Color. The color of the mucous membrane is generally dark red. 
In the acute forms of pharyngitis the color is bright red. In cases of 
heart disease, when there is cyanosis, the veins are congested and the 
surface dusky. In obstruction of the superior vena cava by tumor there 
is a cyanotic hue of the surface of the pharynx. 

Appearance of Surface. The capillary vessels may pulsate in aortic 
regurgitation. Bleeding-points may be seen over the surface of the 
pharynx, the discharges of blood from which may simulate pulmonary 
hemorrhage. The blood may be swallowed and then vomited, and 
hence gastric hemorrhage is simulated. When the hemorrhage occurs 
at night it is seen on the pillow as yellowish stains. It is often due 
to adenoid vegetations in the nasopharynx. In chronic pharyngitis the 
membrane is dry, the glands are prominent, and the secretion viscid. 

On examination of the posterior wall of the healthy pharynx little 
elevations due to glands are seen upon its surface, and moderate-sized 
vessels are seen coursing through the mucous membrane. 

Eruptions. Eruptions may be observed in the pharynx in some of 
the specific fevers. Thus, in measles, the appearance of the rash on 
the pharynx and on the soft palate may be observed before the devel- 
opment of the rash on the skin. The eruption of scarlatina is also seen 
in the pharynx, and the papules and pustules of variola are frequently 
observed in that situation. 

Ulceration. Follicular Ulceration. Small superficial ulcers cor- 
responding to the follicles may be seen over the posterior wall of 
the pharynx. They occur in chronic catarrh, and are due to in- 
flammation of the follicles. In addition, ulcers secondary to infectious 
processes are sometimes seen, as in typhoid fever. In syphilis, in the 
secondary stage, small, shallow ulcers are seen on the posterior wall of 
the pharynx. They do not cause pain. Mucous patches are observed 
at the same time, not only on the pharynx, but also in the mouth. 
In the tertiary stage deep ulcers, followed by scars, are seen on the 
posterior Avail of the pharynx. Although the absence of pain renders 
it probable that they are of syphilitic origin, nevertheless the history 
of infection and of the primary lesion, and the evidence of the disease 
in other structures, ought to be secured before a diagnosis is fully estab- 
lished. In the tertiary forms it may be necessary to resort to the 
therapeutic test. (See The Infections — Syphilis.) 

Tuberculous ulcers are irregular in shape, and the floor grayish. 
They are seen in tuberculosis in its later stages. They are the source 
of extreme pain. There is usually ulceration in the larynx at the same 
time, and, in extremely rare cases, tuberculous ulceration of the tonsils. 
In tuberculous ulceration, after the application of cocaine, a portion 
may be scraped off and examined microscopically for tubercle bacilli. 



710 SPECIAL DIAGNOSIS. 

Cancer of the pharynx is rare, and is usually secondary, the dis- 
ease having spread from other situations. 

Exudations. On the pharynx the exudation may be due to 
diphtheria, to pseudocliphtheria, or to thrush. The method of dis- 
tinguishing the various forms will be considered in the articles on the 
respective affections. In diphtheria the membrane is made up of 
fibrin arranged in a network, in the meshes of which epithelium, 
blood-corpuscles and pus-corpuscles and micro-organisms are found. 
When removed, hemorrhagic abrasions and raw purulent inflammatory 
areas remain. Two forms of bacilli are found in the membrane — the 
pseudodiphtheritic bacillus and the true, or Klebs-Loffler bacillus. 
(See Bacteriology.) The Loffler bacillus is best detected by cultiva- 
tions. After the membrane is removed and washed in a 2 per cent, 
solution of boric acid, it is cultivated in blood-serum. The pseudo- 
diphtheritic bacillus likewise grows, but its appearances are different. 

Anaesthesia. Some of the results of inspection may be confirmed 
by means of the probe, and alterations in the sensibility of the phar- 
ynx may be detected. Sensations may be absent in the whole poste- 
rior wall of the pharynx. Loss of sensation may occur in hysteria, in 
bulbar paralysis, and in diphtheritic paralysis. On the other hand, 
there may be an apparent hyperesthesia. In some individuals the 
pharynx is particularly sensitive to the presence of foreign bodies, such 
as inflammatory exudates, and may resent their presence by sudden 
coughing and retching. Inflammations increase the hyperesthesia of 
the pharynx. The condition is sometimes observed in hysteria. 

The Uvula. In health it hangs midway from the palate. It varies 
in shape from congenital causes, and may be elongated, on account of 
disease. This takes place particularly if there has been hawking or 
coughing, on account of chronic nasal catarrh. When elongated it is 
pointed and may extend almost to the base of the tongue. The uvula 
may be swollen and oedematous. The oedenia is usually associated 
with subcutaneous oedema in acute Bright' s disease. It may occur 
in debility. In both conditions it may become so enlarged as to 
interfere with swallowing and breathing. In some cases of pharyn- 
gitis the uvula is the seat of intense inflammation and great oedema. 
In addition to the constant cough which it causes there may be dysp- 
noea and repeated attacks of choking. 

Hemorrhagic infarcts may take place in the uvula. In two in- 
stances under the writer's care the intense infarction led to sloughing, 
and in one the uvula was swallowed. 

The Cervical Glands. The pharynx is in such intimate rela- 
tion with the large lymphatic glands in the neck that diseases of the 
former are frequently attended by enlargement of the latter. The 
glands at the angle of the jaw are increased in size. The glands ex- 
tending along the vessels of the neck may also be enlarged. In cases, 
therefore, of enlargement of the glands in this situation, it is absolutely 
essential to examine the fauces and pharynx. 

The Tonsils. The tonsils are situated at the sides of the pharynx, 
between the anterior and posterior folds of the palate. They are 
small bodies, not larger than a filbert in the adult. Their entire 



DISEASES OF MOUTH, FAUCES, PHARYNX, OESOPHAGUS. 71 1 

surface can be seen by ordinary inspection. If enlarged, the posterior 
surface cannot be seen, although a larger view may be obtained by 
causing the patient to gag or retch, during which they are brought 
forward to the light. They are pathologically of much importance. 
They are made up of glandular structure arranged in follicles and held 
together by connective tissue. The crypts of the follicles open on 
the surface, and in disease are visible. The diseases of the tonsils 
have nothing to do with their function as far as known. The tissue 
and gland follicles are liable to inflammations, which may be bacterial 
or may be the result of rheumatism. The tonsils become enlarged ; 
the swelling takes place rapidly in the acute forms. They may be 
simply enlarged and the covering membrane intensely red. In other 
forms of inflammation the surface may be dotted over with white 
points, due to exudation from the follicles ; these may be covered with 
a white or grayish membrane, which is removed with difficulty, leaving 
an abraded surface beneath. Repeated attacks of inflammation cause 
chronic enlargement of the tonsils. They are enlarged sometimes to 
a great degree, filling almost entirely the lumen of the fauces. The 
surface is irregular, and may be scarred. The mouths of the follicles 
may be dilated. By virtue of their position, enlarged tonsils from any 
cause are a source of dyspnoea and dysphagia. The tonsils may be 
the seat of sarcoma and tuberculosis. 

Ulcees. Tuberculous ulceration is rare. In a patient, a lad of 
sixteen years, under the writer's care, the large tonsils were of a honey- 
combed appearance, on account of the grayish, irregular ulceration. 
Deglutition was absolutely impossible, on account of pain, and the 
young man died of starvation. 

Exudations on the tonsils are due to inflammation of the follicles, 
to diphtheria, to the pseudodiphtheritic inflammation Avhich attends 
scarlatina, or which arises secondarily to other infectious debilitating 
diseases, and to thrush. 

Leptothrix of the Tonsils. In healthy persons the plugs 
which block the tonsillar crypts are found to be made up of cells and 
segmented fungi. The latter stain bluish-red with iodo-potassic iodide 
solution. Sometimes the micro-organisms extend beyond the follicles, 
covering the surface of the tonsils with patches of various size. They 
are thus seen in follicular tonsillitis. 

Tonsillitis. Acute inflammation of the tonsils may affect the folli- 
cles, to which form the term follicular tonsillitis is applied, or it may 
be limited to the mucous membrane, when it is known as catarrhal 
or erythematous tonsillitis. If with the catarrhal inflammations vesi- 
cles appear on the surface of the mucous membrane, the term herpetic 
tonsillitis is used. When the inflammation extends to the stroma of 
the glands it goes on to suppuration. It is characteristic of all forms 
of acute tonsillitis to recur frequently in the same subject. The rela- 
tionship to rheumatism has been spoken of. This relationship applies 
to both the acute and the suppurative forms. The various forms of 
tonsillitis occur at any age, although it is least common under ten 
years of age ; the suppurative form occurs most frequently in adoles- 
cence. Tonsillitis occurs in both sexes. It may follow exposure to 



7 1 2 SPECIAL DIA GNOSIS. 

wet and cold, although patients who are subject to the attacks bear 
exposure, unless they are at the same time unduly fatigued. The fol- 
licular form of tonsillitis is apparently associated with bad drainage 
or other unhygienic conditions, which makes it possible that noxious 
emanations act as an exciting cause. Several persons of the same 
family may be affected at one time, so that it is often difficult to dis- 
tinguish the cases from diphtheria. The disease, however, is not con- 
tagious. Persons brought in contact with the family, but who do not 
reside in the same house, escape the disease. This applies as well to 
children, who would, if the cases were diphtheritic, be most liable to 
become infected. The disease occurs more commonly in the spring 
than in any other season of the year, more especially in cold and wet 
seasons. 

Symptoms. In follicular tonsillitis, with or without a rigor, but 
always with chilly sensations, the temperature rises rapidly to a great 
height. The subjective sensation of fever is very quickly noticeable 
to the patient, and is generally more pronounced than in other affec- 
tions. With the chill and during the rise of temperature there are 
some frontal headache and severe pain in the back and limbs. The 
pain in the back is most excruciating. In a short time the patient 
complains of pain in the throat. Swallowing is difficult, and there is 
a sense of fulness. The throat is dry and burning. On examination 
the tonsils are found to be swollen, and a yellowish- white exudation is 
seen on the crypts. In twenty-four hours the points may coalesce to 
form a patch. The glands expand slightly, and may extend only 
slightly beyond the arches, or, in younger subjects, one-quarter of the 
way into the lumen of the fauces. Sometimes one gland is affected 
before the other. The difficulty in deglutition increases and the voice 
becomes nasal. There is usually some enlargement of the cervical 
glands. The general symptoms continue for forty-eight hours, the 
temperature remains at 105°, and the pulse is very rapid. After the 
first twenty-four hours the pain in the back lessens. The tongue is 
coated and the breath heavy. The urine is loaded with urates. At 
the end of the fifth day the fever, which subsides gradually, has disap- 
peared. The local symptoms, however, may remain longer ; that is, 
the tonsils are still enlarged and the exudation disappears slowly. 
Sometimes the prostration and general symptoms are very severe, so 
that after the fever has subsided convalescence may be very slow. 

Albuminuria, due in all probability to the fever, frequently occurs ; 
in some cases, undoubtedly, acute nephritis attends the attack and 
retards the convalescence. In a case under the writer's care the 
patient first had acute rheumatism ; this was replaced by a severe attack 
of tonsillitis, during which albumin, blood, and granular casts were 
found in the urine. The swelling of the tonsils subsided in due course, 
but the Bright' s disease continued for a long period, finally ending, 
however, in complete recovery. 

In herpetic tonsillitis the severe pain and intense general symptoms 
arc out of proportion to the local lesion. 

In suppurative tonsillitis the constitutional disturbance is also very 
great. The temperature rises high, 104° to 105°, and the pulse is 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 713 

very rapid, from 110 to 130 in the adult. The inflammation usually 
begins in one tonsil, and the other may be involved later. The 
tonsils at first are enlarged and firm and very red. There is swelling 
of the surrounding tissues. In twenty-four hours deglutition becomes 
almost impossible, and there is salivation. At the end of forty-eight 
hours the patieut presents a striking appearance. The glands of the 
neck are enlarged, the patient is unable to open his mouth, the voice 
is nasal or almost suppressed ; there is dribbling of saliva from the 
mouth. The face may have a dusky hue in spite of the capillary con- 
gestion due to the fever. There is constant desire to discharge saliva 
and accumulated secretions from the back part of the mouth. The 
patient cannot lie down. The pain is extreme, and is aggravated by 
swallowing. It is sometimes of a throbbing character, and often shoots 
to the ears. Indeed, earache may be the chief complaint. The patient 
does not take food, and exhaustion soon ensues. During the twenty- 
four hours before rupture takes place the previously reddened face 
becomes blanched from exhaustion. The fever is continuous during 
this time, with great rapidity of the pulse. The patient may be delirious. 
Sometimes the delirium is marked and the patient resists efforts to keep 
him in bed. 

The suffering is out of proportion to the danger of the case. About 
the fourth or fifth day suppuration is over, and if the finger can be 
inserted into the mouth between the almost closed teeth, fluctuation 
is detected. In cases in which the mouth is opened a little more 
freely, in addition to the swelling of the tonsils below the arches, 
marked swelling and projection forward of the half-arches may be 
seen. The fluctuation may be detected through the anterior fold of 
the palate, and, if lancing is to be performed, the pus can only be 
reached through this structure. In short, a peritonsillitis takes place. 
After spontaneous rupture, which usually takes place into the mouth, 
instant relief is experienced. Rupture may take place into the pharynx 
and cause suffocation from entrance of pus into the larynx. In rare 
cases it has opened into the carotid artery, causing instant death from 
hemorrhage. 

Diagnosis. The diagnostic features of acute tonsillitis are the 
sudden high fever, severe backache and headache, pain in the throat, 
and albuminuria. The characteristic appearance of the face, the sali- 
vation and pain, with suppressed voice and difficult deglutition, should 
distinguish it from trismus or tetanus. In both the jaws are closed. 
It must not be confounded with smallpox, which it resembles during 
the first twenty-four hours. 

Cases of follicular tonsillitis are frequently mistaken for diphtheria. 
The follicular inflammation in tonsillitis is limited to the gland, on 
which patches of a yellowish-gray color, easily removed without leaving 
bleeding surfaces, are seen. In diphtheria the membrane is of an ashy- 
gray color, not in points or small patches, or separated by red tonsillar 
tissue ; it extends to the pillars of the fauces, and may appear on the 
uvula. There are, nevertheless, many cases which are doubtful, when a 
bacteriological diagnosis must be resorted to. (See Bacteriological Ex- 
amination.) A history of exposure sometimes helps us to arrive at a 



714 SPECIAL DIAGNOSIS. 

conclusion. The cases that particularly increase our anxiety are those 
of adults who are subject to attacks of follicular tonsillitis. In the 
grave and extensive forms of diphtheria with asthenic symptoms (sep- 
ticaemia) the diagnosis is not difficult. 

Enlargement of the Tonsils. Chronic Tonsillitis. The ton- 
sils may be enlarged, on account of repeated attacks of acute inflamma- 
tion or from chronic inflammation. They do not appear to cause 
serious symptoms unless associated with adenoid vegetations in the 
nasopharynx. They may interfere with hearing, however, and with 
breathing, and cause snoring at night. Foetor of the breath may be noted, 
particularly if the secretion lodges in the crypts. The latter may be 
recognized by its characteristic yellowish color and by its odor on 
removal. The enlarged tonsils are irregular in contour. 

Foreign bodies in the tonsils are not of common occurrence. They 
give rise to local symptoms, as the sensation of the presence of a mass 
causing repeated efforts at swallowing. If calculi are present the 
patient may complain of a rough sensation. The calculi follow frequent 
attacks of quinsy. Hydatids are sometimes located in the tonsils. 

Adenoid Vegetations of the Nasopharynx. Adenoid vegetations 
cause more or less obstruction in the nasopharynx. The symptoms 
may be classed as primary and secondary. The former are local, and 
due to the foreign substance, per se ; the latter are local and general. 
The former are catarrhal ; the latter the result of stenosis. 

Local Symptoms. In a large number of cases there is discharge 
from the nose. This may be mucopurulent, or be associated with 
crusts. If the discharge is not constant, the child is subject to coryza, 
with its customary discharge, on the slightest provocation. With or 
without the chronic purulent nasal discharge mucus and blood may 
be passed at night and found on the pillow in the morning. 

The hearing is frequently impaired. There may be simply dulness 
of hearing, or it may amount to marked deafness, either because of 
pressure of the adenoid vegetations, or extension of secondary inflam- 
mation to the Eustachian tubes. The senses of taste and smell are often 
much impaired. There is increase in the secretion of pharyngeal 
mucus, which in older persons causes difficult expectoration. 

Rhinoscopic Examination. The roof of the pharynx is covered 
with rounded or villous projections, often concealing the posterior 
nares. Rarely the villi may be seen projecting below the soft palate. 
In children the examination is difficult, and hence digital exploration 
must be used under an ansesthetic. The finger readily detects the 
masses, which sometimes are soft, at other times tough and of fibrous 
or cartilaginous consistency. 

The Appearance. The expression of the face is characteristic. 
It is dull and stupid, and may be drawn. (Fig. 187.) The mouth is 
kept open in breathing. The lips are dry, and may be cracked. They 
are thickened. The palatal arch is high and narrowed. 

The nostrils are flattened laterally. Rarely they may be depressed. 
In one instance, which the writer saw with Dr. Harrison Allen, the 
exterior of the nose suggested inherited syphilis, all the more because 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 715 



Fig. 187. 




of our knowledge of the possible presence of the disease. There were 
no other evidences of hereditary syphilis in the child or in any mem- 
ber of the family. 

The Voice. It is thick and muffled, becoming indistinct upon the 
occurrence of slight cold. 

The Chest. While there is a general lack of physical development, 
the appearance of the chest is most striking. The cases have been 
frequently mistaken for rickets, however ; in this country adenoid veg- 
etations are a common cause of chest- 
deformity, whereas in England and on 
the continent rickets is the most frequent 
cause. The ribs are prominent in front, 
the sternum is angulated forward at the 
manubrio-gladiolar j unction and grooved 
at the gladiolar-xiphoid junction. A 
saucer-shaped depression is found at 
the lower costal cartilages. The ribs 
behind are closely compressed, so that 
the intercostal spaces at the lower part 
of the chest are obliterated. The chicken- 
breast appearance is most striking, with 
the depression in the lower portions of 
the chest. The diaphragm may be 
drawn in during inspiration in the 
middle and lateral thoracic regions. 

In addition to the " chicken " or 
" pigeon-breast " the more advanced 
deformity known as the "funnel-breast 7 ' 
or trichterbrust is seen. In children 
who suffer from asthma and bronchitis, 
the chest becomes emphysematous. 

Mental and Nervous Symptoms. 
Headache, listlessness, and indisposition 
for mental exertion are marked. The 
patients are usually backward in their 
studies and are unable to fix their at- 
tention for any length of time upon any 
subject. The child is forgetful and can- 
not study without effort. Aprosexia is 
the term applied to this condition. 

Choreiform spasm of the face occurs 
in connection with it. Enuresis is a 
frequent associate symptom. The child 
is subject to frequent attacks of indiges- 
tion. I have seen the following occur in many cases : Prior to opera- 
tion the child had an abnormally poor appetite and was subject to fre- 
quent attacks of indigestion, characterized by vomiting, with fever. 
After the operation the appetite improved and continued good, and 
the attacks of indigestion disappeared entirely. The cases had been 
under observation before and after the operation for a number of years. 




Appearance in adenoid disease. 
(D awson- Willi ams . ) 



716 SPECIAL DIAGNOSIS. 

The indigestion seems to have been due to the fact that, owing to the 
obstruction, the child would have to eat rapidly, in order to keep the 
lumen of the mouth free for breathing purposes. The rapid eating, 
of course, prevented proper mouth-digestion, and hence the occurrence 
of gastric catarrh. 

Symptoms from Embarrassed Respiration. In addition to 
mouth-breathing, the patient snores at night, and sleep is always dis- 
turbed. The respirations are irregular, with a pause between, fol- 
lowed by noisy inspirations. The difficulty of breathing is the cause 
of restlessness, and the child will often wake up in the night with 
dyspnoea. Night-restlessness, with dyspnoea and irregular respirations, 
should point, therefore, to obstruction in the nasopharynx. 

Diagnosis is based upon the facies, which is very characteristic, and 
the physical examination. In children, digital examination is neces- 
sary. The finger can readily detect small, flat bodies or grape-like 
masses in the nasopharynx. 

The student cannot become too familiar with the symptoms and 
signs of adenoid disease of the nasopharynx. There is no doubt that 
in our large cities this local affection is of more common occurrence 
and more disastrous in its results than any other that we have to deal 
with in children. It may be said that in children in poor health, 
anaemic, with impaired digestion, and lack of muscular and physical 
development, if the causes are not due to impure air and improper 
diet, or to improper sanitation generally, it is almost certain that there 
is disease of the nasopharynx. The writer has seen a very large num- 
ber of cases in recent years in his practice, and has had the satisfac- 
tion of seeing the entire picture of the child change after proper opera- 
tions. It may be said in passing that this change does not take place 
at once, but after three to twelve months the child will be fully 
restored in physique, if during that time attention is paid to proper 
exercise and the development of the chest. Notwithstanding all this, 
however, the natural shape of the chest and appearance of the face are 
only resumed gradually. 

Inflammations of the Pharynx. Inflammation of the pharynx, 
acute pharyngitis, or sore-throat, follows cold or exposure, particularly 
after the patients have been physically depressed. The acute inflam- 
mation may be associated with rheumatism or gout. The inflammation 
often involves the tonsils as well as the pharynx. The symptoms are 
pain on swallowing, with dryness and a constant desire to hawk and 
cough, on account of the tickling sensation. There may be slight 
laryngitis and inflammation of the Eustachian tubes, with' deafness. 
Stiffness of the neck and enlargement of the cervical glands attend the 
local inflammation. The general symptoms are not marked. The 
attack is ushered in by chilliness and slight fever. On examination 
the mucous membrane is seen to be congested, dry, and glistening, 
and covered in spots with sticky secretions. The uvula may be very 
much swollen. When the submucous tissues are involved the parts 
are more swollen and there is greater dyspnoea. The dysphagia is 
more marked, although the pain is not any greater. The fever is 
higher. The larynx is always involved, causing aphonia. 



DISEASES OF MO UTH, FA UCES, PHAR YNX, CESOPHA GUS. 717 

Phlegmonous Inflammation. A diffused inflammation of this 
character occurs. The writer saw one case with dyspnoea, nervous 
symptoms, and high temperature, simulating severe pneumonia. 
Pneumonia was thought to be present because there were congestion 
and oedema of the lungs. It occurred during the prevalence of the 
recent epidemic of influenza. The disease began in the pharynx ; the 
tissues were swollen and infiltrated. The early symptoms were phar- 
yngeal. The dysphagia was extreme, and there was an abundant 
mucopurulent expectoration, which did not contain pneumococci. 
Death took place on the ninth day from exhaustion. The autopsy 
showed a high degree of congestion of the lungs, and phlegmonous 
inflammation of the pharynx, larynx, and trachea. While, therefore, 
the recognition of an acute phlegmonous inflammation is not difficult, 
it must not be forgotten that it is a grave disease, which may present 
such marked pulmonary and systemic symptoms as to lead to the sus- 
picion of pneumonia. 

Angina Ludovici is an inflammation of the cellular tissue of the 
floor of the mouth and neck. It is probably a form of actinomycosis. 
The swelling is most marked below the jaw of one side. The symp- 
toms are very intense and both local and general. There are general 
septic symptoms from the outset. With the swelling there are oedema 
and board-like induration. Redness and the rapid formation of an 
abscess occur rarely. The throat is not affected. Death takes place 
from reflex suffocation or in coma. (See The Mouth.) 

Rheumatic pharyngitis is of short duration, without objective 
symptoms. Pain is intense, deglutition difficult. The usual concomi- 
tants of rheumatism are present. It frequently gives place to torti- 
collis, lumbago, or rheumatism in some other situation. 

Chronic pharyngitis follows acute attacks, and is a frequent 
accompaniment of nasal catarrh. It is common in smokers and alco- 
holic subjects ; the use of the voice in loud tones, as by clergymen, 
auctioneers, etc., is also a cause. It is a frequent attendant upon in- 
digestion, due probably to the eructations. The objective signs are 
relaxation of the mucous membrane, with dilatation of the veins. The 
membrane is covered with a thick secretion, which is dry and glisten- 
ing. In the granular form the wall of the pharynx is covered with 
millet-seed projections and is congested. Tough mucus is seen in 
small areas. 

Retropharyngeal Abscess. The inflammation may begin in 
the submucous connective tissue, and a retropharyngeal abscess form. 
There are high fever and dysphagia, with stiffness of the neck and 
enlarged glands. On examination a projection into the pharynx can 
be seen or distinctly felt on the posterior wall. The disease may be 
difficult of recognition in infants, in whom it is not possible to get a 
good view of the pharynx. On the other hand, it may be simulated 
by disease of the cervical vertebrae, in which there may be stiffness, 
difficulty in deglutition, and possibly a tumor. It must not be for- 
gotten that retropharyngeal abscess may result from caries of the cer- 
vical vertebrae. In children the abscess is attended with dyspnoea and 
alteration in the voice, so that laryngeal disease may be suspected. I 



718 SPECIAL DIAGNOSIS. 

recall a case of retropharyngeal abscess in which the dyspnoea was so 
severe as to suggest croup ; in fact, preparations for tracheotomy were 
made, when sudden rupture of the abscess revealed the nature of the 
disease. Fortunately the child had been kept in the upright position, 
so that pus was discharged into the mouth, or suffocation would have 
ensued. 

Inflammation of the Parotid Gland. First, specific inflammation 
or parotitis (see Mumps) ; second, symptomatic parotitis occurs in 
typhoid fever, pneumonia, pyaemia, and septicaemia. The process is 
intense, characterized by swelling, redness, and heat over the parotid 
gland. There are pain and difficulty of mastication ; suppuration 
rapidly ensues in the septic form. It is thought to be an unfavor- 
able symptom, but I have seen two cases in typhoid fever get well. 
In a case of septicaemia it did not advance to suppuration. Stephen 
Paget has described a symptomatic inflammation in disease of the 
abdomen and pelvis. He collected 101 cases, 50 of which were due 
to injury, disease, or temporary derangement of the genital organs, 
as by slight blows, or in females to the introduction of a pessary. It 
may occur before the menstrual period or during pregnancy. Septi- 
caemia or pyaemia does not attend the process — indeed, many of the 
cases are afebrile. In 78 cases, 45 suppurated and 33 resolved with- 
out suppuration. 

Gowers describes a case of parotitis which occurred in the course of 
fatal peripheral neuritis. 

The (Esophagus. 

The oesophagus is open to all affections which arise in mucous mem- 
branes, although its histological structure, its position, and its func- 
tions largely protect it from involvement in disease. Should morbid 
processes arise, the symptoms expressive of these processes are the 
common symptoms of disease of the mucous membrane. But the oesoph- 
agus is a closed tube, the function of which is to convey food from 
the pharynx to the stomach. It is subject to all the affections common 
to channels. Any disease of the tube interferes with its function, 
made evident by the symptom common to all disorders of the oesoph- 
agus — dysphagia. As this symptom occupies a position of such promi- 
nence in the symptomatology of disease of this tube, it is evident that 
the diagnosis of disease resolves itself into the differentiation of all 
forms of difficulty of deglutition. 

Before beginning the discussion along the lines indicated, the sub- 
jective and objective symptoms of disease of the oesophagus must be 
considered. 

The Subjective Symptoms. Pain is a common symptom of dis- 
ease of the oesophagus. In acute inflammation it is extreme, and is 
complained of in the neck, between the shoulders, and along the verte- 
brae for a short distance. Its character depends upon the cause. Severe 
burning pain, often agonizing, is due to inflammation caused by hot 
or caustic fluids. Absence of pain after the ingestion of such sub- 
stances, or its disappearance in a short time, points to extreme corro- 
sive action and gangrene. Pain attends and is a part of the symptom 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 719 

— dysphagia (q. v.). Cough attends such diseases of the oesophagus as 
exert pressure upon the bronchus, as carcinoma. 

The Objective Symptoms. Stiffness of the neck is seen in acute 
inflammation of the oesophagus and in peri-oesophageal abscess ; it 
may also occur in traumatism. The expectoration in diseases of the 
oesophagus is characteristic. It is usually a glairy mucus, often frothy 
or viscid. It is not coughed up, but after welling into the pharynx 
is hawked up. It is abundant in acute and chronic inflammation and 
in cancer. 

Hemorrhage from the (Esophagus. Hemorrhage from the 
oesophagus occurs from varicosity of the veins at the lower portion of 
the gullet. It may occur in old people, from senile disease of the 
liver, kidney, and spleen, or at any age in cirrhosis of the liver. In 
hemorrhage from the oesophagus the blood is usually bright in color, 
has not been acted on by an acid, as in hsematemesis, and is, therefore, 
alkaline in reaction, and is not discharged by vomiting, although vom- 
iting may occur after the blood is poured out. In a grave case of 
purpura under the care of the writer hemorrhage took place from the 
lower end of the oesophagus. Small bleedings from the oesophagus are 
usually indicative of cancer, especially if, in addition to the hemor- 
rhage, there are present the symptoms of occlusion. Hemorrhage is 
also seen in foreign bodies : (1) from trauma ; (2) from ulceration. 
Emaciation is the most characteristic general symptom of oesophageal 
disease. It is, of course, more striking in cancer, but occurs to a mod- 
erate degree in all forms of stricture. Factor of the breath attends 
dilatation of the oesophagus. 

Emphysema of the subcutaneous connective tissue should always lead 
to investigation of the oesophagus. Usually it is found to have been 
preceded by pronounced symptoms of disease of the oesophagus. In 
rare cases ulceration of the oesophagus may progress without symp- 
toms, and extend into the air-passages. The passage of air through 
the fistulous communication causes subcutaneous emphysema. It is of 
frequent occurrence wheu foreign bodies lodge in the gullet. 

Physical Examination. Examination of the oesophagus is made 
by inspection and auscultation, and by means of palpation with or 
without a bougie. 

Inspection can be made only with an endoscope. 

Auscultation of the oesophagus, while the patient is swallowing 
fluids, sometimes confirms the results obtained by instrumental palpa- 
tion as to the seat of an obstruction. A gurgling sound is audible to 
the left of the spine as the fluid passes the obstruction. 

Palpation. The oesophagus behind the trachea in the neck may be 
palpated when it is enlarged, as in abscess. Palpation yields the 
most positive results. 

It must not be forgotten that the normal constriction of the oesoph- 
agus is situated nearly opposite the fourth dorsal vertebra, ten inches 
from the teeth. The bougie is used to determine the cause of diffi- 
culty in swallowing. If the cause is due to paralysis or to spasm of 
the oesophagus the bougie can usually be passed with ease. If, on 
the other hand, it is due to organic disease, an obstruction will be 



720 SPECIAL DIAGNOSIS. 

found. In organic disease this is generally in the upper half of the 
oesophagus. If near the pharynx, the obstruction is due to cicatricial 
stricture. If the obstruction is encountered nine inches from the teeth 
or about the position of the bronchus, it is usually due to cancer. 
The bougie should not under any circumstances be passed if there are 
grounds for believing there is an aneurism. Fatal rupture has fol- 
lowed its passage under such circumstances. 

Method. The patient should be seated with the head thrown back 
sufficiently far to make the passage from the pharynx to the oesopha- 
gus almost continuous. The operator may stand behind or in front of 
the patient. The bougie, held like a pen, should be passed through 
the pharynx, guided by the fingers, close to its posterior wall. But 
little force should be used. It should be passed slowly, when the 
gagging will soon be overcome. The bougie should be warmed and 
oiled before it is introduced. The handles should be flexible, the bulb 
olive-shaped. 

Obstruction of the (Esophagus. Dysphagia is a symptom com- 
mon to all diseases of the oesophagus. It may vary from simple pain- 
dysphagia to complete obstruction of the tube. Dysphagia from ob- 
struction of the oesophagus is due (1) to disease outside of the canal 
(external pressure), (2) to disease of the canal itself, and (3) to the pres- 
ence of a foreign body in the canal. In the consideration of this symp- 
tom, therefore, these conditions must be studied. 

1. External Pressure. The oesophagus at different parts of its 
course is in intimate relationship with the trachea, the thyroid gland, 
the carotid artery, the left bronchus, the bronchial glands, the arch of 
the aorta, and the descending aorta. Disease of these structures at- 
tended by enlargement may, therefore, cause difficulty in swallowing. 
It is not likely that difficulty of deglutition from disease of the trachea, 
thyroid gland, or carotid arteries will be overlooked. If the trachea 
is affected, dyspnoea will be a prominent symptom ; if the thyroid 
gland, dyspnoea will be associated with dysphagia, and the enlarged 
gland will be visible from the outside. Disease of the vertebrae is 
not likely to cause obstruction of the oesophagus, for it would not press 
that organ against any other solid structure. Disease of other struc- 
tures, however, may cause difficulty of deglutition by pressing the 
oesophagus against the vertebrae. Within the thorax, disease of the 
mediastinal glands, aneurism of the arch, or descending portion of the 
aorta, an enlarged left auricle, a pericardial effusion or disease of the 
left bronchus might cause constriction of the oesophagus. The medi- 
astinal glands are enlarged from tuberculosis, carcinoma, sarcoma, or 
syphilitic disease. The occurrence of physical signs of a mediastinal 
tumor, with a history of syphilis or the general symptoms of tuber- 
culosis, sarcoma, or carcinoma, would point to the presence of these 
affections. In aneurism of the aorta, in its arch or transverse portion, 
the physical signs and subjective symptoms of aneurism — with accent- 
uation of the aortic second sound and the presence of atheroma — 
would lend color to the view that the obstruction was of this nature. In 
both instances just mentioned the obstruction rarely goes to the extent 
of preventing the passage of liquids. In enlargement of the left auri- 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 721 

cle and in pericardial effusion the degree of difficulty may amount 
simply to a temporary sense of obstruction or pain about the point 
where food passes these structures. If the early physical signs are 
associated with an enlarged auricle, with mitral stenosis, or with peri- 
cardial effusion, the diagnosis of the causal condition is easy. It is 
particularly important, in considering difficulty of deglutition from 
external pressure, to remember that the oesophagus is in close relation 
with the bronchus on the left side, at about the fourth dorsal vertebra 
—ten inches from the teeth — in case it is desirable to investigate the 
obstruction with a probe. Obstruction from aneurism of the descend- 
ing portion of the arch of the aorta is also located at the upper portion 
of the oesophagus, nine inches from the incisor teeth. 

2. Organic Disease. Difficulty of deglutition, due to disease of 
the oesophagus itself, occurs in acute inflammation, in chronic inflam- 
mation, and in stricture, which is always the result of traumatic in- 
flammation, syphilis, or cancer. 

Acute inflammation is recognized by severe pain on swalloAving. It 
is associated with the sensation of a foreign body in the lower portion 
of the throat. There may be tenderness on pressure along the course 
of the pharynx. The pain is aggravated by speaking. The pain may 
extend along the vertebral column to the cardiac end of the stomach, 
and is usually of a burning or raw character. When the inflammation 
is due to traumatism, as the swallowing of acids or other caustics, the 
mouth and pharynx show the effects of the inflammation, and, in addi- 
tion, there is agonizing, burning pain at the root of the neck and be- 
tween the shoulders. The inflammation is usually attended by erosion 
of the mucous membrane, and hence not only frothy mucus of a glairy 
character is expectorated, but also blood and shreds of membrane. 
The effect of the corrosive poisoning on the general system is marked. 
There is great prostration. Because of the accompanying gastritis 
there is intense thirst. Acute inflammation of the oesophagus may 
end in ulceration or in resolution. The traumatic inflammation is 
followed by chronic inflammation, which ultimately results in stricture. 

Chronic inflammation is attended by pain in the act of swallowing ; 
liquids are swallowed readily, but solids with great difficulty. Viscid 
mucus is expectorated, usually in large amounts. 

Abscess of the (Esophagus. The acute inflammation may terminate 
in abscess. The abscess usually develops slowly, with pain on swal- 
lowing and on movements of the neck. When the abscess is high 
up in the gullet it may present on the exterior of the neck. If it is 
situated outside of the oesophagus, and is secondary to disease of the 
vertebrae, it. is slow and chronic in its course ; fever and rigors attend 
its development. 

Stricture of the oesophagus due to the healing of ulcers, following 
traumatic inflammation, is recognized, first, by the gradual development 
of the symptoms, by the painless nature of the obstruction in the large 
majority of cases, and by its seat. It is readily found by the use of a 
bougie ; the patient can sometimes localize the area in the upper por- 
tion of the oesophagus. The difficulty of deglutition continues over 
such a long period of time that the nutrition is but slowly interfered 

46 



722 SPECIAL DIAGNOSIS. 

with, but gradual emaciation with coincident anaemia develops eventu- 
ally. 

Carcinoma of the (Esophagus. In cancer of the oesophagus dys- 
phagia is the most prominent symptom. It comes on gradually. The 
patient expectorates a considerable quantity of frothy mucus, often 
containing blood, and revealing, on careful examination, cancerous 
tissue at times. Pain is not generally very severe. Cough is usually 
present, due to pressure of the cancerous mass on the recurrent laryn- 
geal or pneumogastric nerve. Sometimes the cancer develops in the 
anterior wall, and ulcerates into the trachea or bronchus. When this 
complication takes place the cough is violent. Dyspnoea from pressure 
is likely to occur. Perforation of the oesophagus into the air-passages 
is followed by pulmonary abscess or gangrene, or the sudden appear- 
ance of dyspnoea, and shortly the onset of aspiration pneumonia. 
When ulceration causes a pulmonary oesophageal fistula the condition 
may simulate that of phthisis. 

The difficulty of deglutition due to cancer must be distinguished 
from that of traumatic or syphilitic stricture and from spasmodic stric- 
ture and paralysis of the oesophagus. The history of the case aids in 
the recognition of traumatic or syphilitic stricture, Avhile the ready 
passage of a bougie indicates that the difficulty is spasm or paralysis. 
Cancer usually occurs late in life and is attended with rapid emacia- 
tion. Its complications, more common than in other obstructions, are 
attended with fever and rapid prostration. Cancer may be distin- 
guished from disease outside of the oesophagus by the condition of the 
stomach beyond the point of stricture. If there is cancer, atrophy is 
more likely to take place, the change in size being recognized by a 
tube or by inflating the stomach with air or fluids. 

Sarcoma of the oesophagus is very rare. It occurs most frequently 
in males and presents symptoms like those of carcinoma. 

3. Foreign Body. Stricture or difficulty of deglutition from the 
presence of foreign bodies is usually recognized with ease. The diffi- 
culty of deglutition is due both to the foreign body and to the spasm 
excited by the mass. In consequence of the latter regurgitation of 
food takes place. In the first place, there is a history of the swal- 
lowing of a foreign material. Sudden pain succeeds the act, while 
there are great anxiety and distress, particularly if the body is a large, 
hard mass. Not only is there difficulty in deglutition, but also dysp- 
noea. The latter is due to pressure, but is aggravated by the nervous 
state. When the foreign body is small the dysphagia is moderate in 
degree and the reflex irritation slight, although nausea and vomiting 
may be common. If it cannot be removed, ulceration and abscess 
result, the further course of which depends upon the seat of the ob- 
structing material. Pain, hemorrhage, subcutaneous emphysema, and 
the emission of air are symptoms which follow. The exact location 
of the foreign body may be ascertained by the use of the Rontgen rays, 
as in the remarkable case of White's. 

Harrison Allen 1 , in his exhaustive essay, calls attention to several 

1 " Foreign Bodies in the (Esophagus." Allen : New York Medical Journal, August 
17, 1895. 



DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 723 

features. Many of the symptoms are primary and some are secondary. 
The former are due to the trauma and the presence of the foreign body ; 
the latter to the secondary ulceration. This softening and ulceration 
of the walls may take place rapidly. Allen does not think that pain 
or the occurrence of convulsions is of much significance, but that em- 
physema, the excessive secretion of mucus, and the emission of air are 
important signs. Anxiety he considers of very common occurrence 
and very suggestive. The excessive secretion of ropy mucus, saliva- 
tion included, is, in Allen's judgment, pathognomonic of disease in 
the pharyngo-larynx or in the oesophagus, at or above the level of the 
left bronchus. This secretion may be an early indication of cancer of 
the oesophagus. It may occur in aneurism. 

Dilatation of the (Esophagus. Primary dilatation of the oesopha- 
gus is an extremely rare affection. The chief symptom is the regurgi- 
tation of food, which is neutral or alkaline, and may be returned some 
time after the act of swallowing. The patient sometimes complains of 
a sensation of distention along the course of the oesophagus, with heat 
and burning. The odor of the breath is foetid. If the oesophagus is 
not deflected, a bougie can be passed through its course. 

If the dilatation is secondary, the amount of dysphagia depends 
upon the obstruction. Food, however, is not returned immediately. 
After remaining an indefinite time, not longer than two hours, it is 
regurgitated unchanged. Bougies, of course, do not pass. In saccu- 
lated dilatation, which usually takes place in the posterior wall near 
the pharynx, a bougie may sometimes pass, and at other times may be 
caught in the sac. The sac may be enlarged, so as to retain a consid- 
erable amount of food, which is regurgitated some time after it is swal- 
lowed. A sacculated diverticulum, from traction on the outside of 
the oesophagus, may occur when there is glandular disease of the neck, 
with adhesions to the oesophagus. 

Functional Affections of the (Esophagus. The functional affec- 
tions are quite as common as organic disease. They are of longer 
duration, but are unattended by the same grave effects upon the gen- 
eral system. Spasm is one of the most frequent affections. It may 
be so intense as to lead to temporary stricture. It usually occurs in 
women. The attack comes on suddenly during the act of swallowing 
food. The food is at once regurgitated. After the subsidence of the 
perturbation, swallowing can be accomplished, if it is done slowly. 
It usually occurs in hysteria. The patient may have had some slight 
accident in the performance of the ordinary act of deglutition, out of 
which grew the idea that swallowing cannot be accomplished. In 
consequence, the further acts are performed with trepidation, and slight 
emotional disturbance at the table may cause a recurrence of the sud- 
den spasm. 

Unfortunately calling attention to the act of swallowing always has 
the effect of embarrassing the patient, and the taking of a meal under 
unusual circumstances is sure to be attended by complete dysphagia. 
Sometimes the idea is conceived that certain forms of food alone can- 
not be swallowed. It is usually thought that solid food gives the 
distress. Mitchell says that the dysphagia occurs early in cases of 



724 SPECIAL DIAGNOSIS. 

hysteria ; unless relieved, the hysterical symptoms are likely to be 
transferred to the stomach. I saw a female patient who, after an 
ordinary choking attack, for several years could not swallow food in 
the presence of strangers, or after the slightest emotional disturbance, 
or if hurried. The spasm disappeared after treatment with bougies. 

In paralysis difficulty of deglutition is the main symptom. The 
course of oesophageal paralysis depends upon its cause. The larynx is 
usually affected at the same time, so that laryngeal symptoms are 
present. Paralysis generally comes on very gradually. It may be 
due to cerebral hemorrhage, tumor, bulbar paralysis, or to general 
paralysis of the insane. The bougie passes easily, and does not cause 
irritation. In paralysis there is no regurgitation of food. 



PLATE XXXV. 







Quadrants of the Abdomen. Position of the Viscera. 



Liver and colon— red lines. Stomach, kidneys and bladder — solid green lines. 
Pancreas— dotted green lines. 



CHAPTER V. 

DISEASES OF THE STOMACH, INTESTINES, AND PERITONEUM. 

The abdomen is divided arbitrarily into regions, to enable us to 
locate the various organs in health and in disease. Simplicity is essen- 
tial, and a method of delimitation that is commonly used in the subdi- 
vision of other regions should be adopted, for the sake of uniformity of 
description and to assist the memory of the learner. For these reasons 
Ballance's method of dividing the surface is the best. This author 
includes the abdomen within a circle which has the umbilicus as its 
centre. The circle is divided into quadrants by diameters drawn at 
right angles, corresponding to the median and transverse umbilical 
lines. The portions to the right of the middle lines are the right 
upper and lower quadrants, respectively ; the portion to the left, the 
left upper and lower quadrants. (See Plate XXXV.) 

With the abdomen thus divided, the umbilicus and fixed bony struc- 
tures in the periphery of the circle serve as points from which meas- 
urements are made to indicate the exact position of the structure. The 
circle may be further divided by other radii. To locate a tumor in 
the right lower quadrant, for instance, the umbilicus, pubic bone, and 
anterior spine of the ilium may be used as points from which to meas- 
ure the distance. Measurements may also be made along the radii 
extending from the umbilicus to fixed points. The following illus- 
trates a useful method : A tumor is situated in the right lower quad- 
rant ; the centre of the tumor is two inches below a point on the transverse 
umbilical line, three inches from the centre ; it is also three inches 
to the right of a point on the median line, two inches from the umbili- 
cus. The size of the tumor can be defined by measurements from its 
own centre. Organs bisected by the median line, as the bladder and 
uterus, can be described as situated in the median line, so many inches 
to the right and left, as the case may be, and so many inches from the 
pubis. 

The right upper quadrant includes the right lobe of the liver, the 
gall-bladder, the hepatic flexure of the colon, and part of the trans- 
verse colon, a portion of the pancreas, the pyloric orifice near the me- 
dian line, and, deeper, the upper half of the kidney ; the left upper 
quadrant, the left lobe of the liver, the stomach, part of the transverse 
colon and the splenic flexure, the pancreas, the upper portion of the 
kidney and the spleen ; the right lower quadrant, the caecum, the ascend- 
ing colon, appendix vermiformis, right tube and ovary, a portion of 
the bladder and uterus, and, above, the lower part of the kidney at the 
end of full inspiration ; the left lower quadrant, the corresponding tube, 
ovary, and portions of the bladder and uterus, the descending colon, 
and the sigmoid flexure, but not likely the lower part of the kidney, 
as it is one-half inch or more higher than the right (Holden). About 



726 SPECIAL DIAGNOSIS. 

the centre and extending to the periphery on all sides are the small and 
large intestines. 

The Data Obtained by Inquiry. The Subjective Symptoms 
of Abdominal Disease. 

This class of symptoms will be discussed in the articles devoted to 
affections of the particular organs of the abdomen, because the symp- 
toms are usually directly referred by the patient to the affected organs. 
They are local sensations of heat, fulness, or distention, of burning, 
of pain, of weight, or of undue motion. Local sensations of weight, 
fulness, or distention are due to enlargements or to displacements of 
organs (liver, kidneys), or to tumors. Heat or burning is described 
in inflammatory tumors, as pyosalpinx. It is often difficult for the 
sufferer to define the location of pain in the abdomen and describe its 
features. Moreover, the pain is frequently due to disease of the walls 
of the abdomen, which may increase the confusion. Pain must be in- 
vestigated by an examination of each structure in close proximity to 
the part complained of. The state of the function of each organ must 
also be inquired into. 

Pain Confined to the Abdominal Walls. The skin, the 
nerves, the muscles and fascia, the connective tissue, may be the seat 
of pain. If the skin is affected, the pain is usually localized and of 
moderate degree of severity. There is superficial tenderness. There 
are evidences of inflammation, as erythema or ulcers. Pain due to 
affections of the nerves is seen in simple neuralgia and herpes zoster. 
Herpes zoster is recognized by the localized neuralgic character of the 
pain in the distribution of superficial nerves and the peculiar eruption 
which follows. Neuralgias are recognized by the well-known points 
of tenderness, the intermittent character of the pain, and the association 
with anaemia ; neuritis may be present, with the usual objective signs. 

Rheumatism. The muscles and fascia may be the seat of rheuma- 
tism, causing severe pain. The muscles are tender. Movement always 
increases the pain, and sighing, laughing, or coughing aggravates it. 
The pain may be diffuse and severe, causing it to be confounded with 
peritonitis. The presence of rheumatism in other muscles, of moderate 
fever without gastro-intestinal disturbance, of uric acid and urates in 
excess, due to the rheumatic diathesis, point to the true condition. 

Referred Pain. A common cause of pain in the abdomen is dis- 
ease of the vertebrae, with pressure upon the peripheral nerves at their 
emergence from the spinal column. The pain is situated in the median 
line, either below the ensiform cartilage or around the navel ; it is an 
intermittent pain. Aneurism of the abdominal aorta, with pressure 
upon and erosion of the vertebrae, causes the same kind of pain. 

Pain within the Abdomen. The seat of the pain, if general or 
local, will be considered in discussing the special organs and their 
diseases. In general, it may be said that the seat of the pain is a fair 
index of disease of some structure in the part indicated. When the 
pain is general it points to rheumatism or to peritonitis. 

Character of Pain. Attacks of severe pain in the abdomen may be 
sudden in onset, or the culmination of slight sensations of discomfort 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 727 

progressively increasing in severity. The pain may be of brief dura- 
tion or may continue over a long period of time. Sadden acute pain 
points to inflammation, to perforation of some one of the hollow viscera, 
to gastralgia, to enteralgia, flatulent distention of the stomach or of 
the intestines, or to occlusion of channels, of which the abdomen 
contains so many. Attacks of sudden pain are spoken of as colic; 
the onset is sudden ; the pain is paroxysmal ; each spasm of pain may 
be attended by vomiting, rapid pulse, cold extremities, cold sweat, and 
more or less collapse, except in lead-colic. Such pain is seen in intes- 
tinal colic, hepatic colic, renal colic, and in uterine and vesical colic. 
Sudden acute pain occurs in perforation of some one of the hollow 
viscera, indicated by the history and location of the disease of the part 
affected and the character of the symptoms attending the pain. Thus, 
in a case of gastric ulcer, sudden pain indicates possible perforation, 
which may take place in the course of the disease. Chronic pain points 
to ulcer, to chronic processes, or to gastric or intestinal neurosis. 

The Data Obtained by Observation. 

The Objective Symptoms. It must be remembered that objective 
symptoms of abdominal change are not alone due to disease of the ab- 
dominal contents, but also to disease elsewhere. Thus the abdomen 
may be enlarged from the ascites of cardiac or renal disease, contracted 
in tuberculous meningitis. 

Disease or paralysis of the diaphragm alters the appearance of the 
upper half of the abdomen and its movements in respiration. Fluctu- 
ating changes in size occur in hysteria and gastric neurasthenia, and 
permanent change in tuberculous meningitis. 

Inspection. We note the appearance of the abdominal walls, the 
movements of the abdomen, its general shape and size,local enlargements. 

The Abdominal Walls. A glance suffices to tell of the thick- 
ness of the abdominal walls. Thin walls are due to absence of adipose 
tissue and of muscular structure associated with general atrophy (see 
Emaciation), on the one hand, or sometimes in consequence of intra- 
abdominal pressure. Frequent pregnancies, previous ascites or ante- 
cedent growths (ovarian tumor) lead to atrophy of the muscles ; the 
recti separate and hernia-like protrusion of abdominal contents results. 
Furthermore, a conical projection of the lower median portion of the 
abdomen is brought about, especially if ascites is present. Such pro- 
jections are often confusing when tapping is to be resorted to. Thick 
walls are due to oedema or to increase in fat. 

The Color. The abdomen, in general, partakes of the hue of the 
skin. It is darker around the umbilicus. In Addison's disease a dis- 
tinct areola often forms. The median line, from the umbilicus to the 
pubis, darkens in pregnancy — the " brown line." It is sometimes 
seen in men. The skin of the abdomen is the seat of specific erup- 
tions, as in typhoid fever, and of sudamina. The walls may be pale 
and glistening in oedema. 

Markings. In first pregnancies and great ascites, less frequently in 
obesity and tumors, strice are produced in the parts of the skin where 



728 SPECIAL DIAGNOSIS. 

the tension has been greatest. In pregnancy they form sinuous lines 
upon the lower lateral portions of the abdominal wall and upon the 
upper inner portions of the thighs. When first developed they are red- 
dish, but subsequently become, by a process of fading, more glistening 
and white than the rest of the skin. They are also known as " water 
lines," and linece albicantes. Rarely they are seen after typhoid fever. 

The umbilicus may project from hernia or may be prominent in 
ascites. The veins about the umbilicus are often enlarged in cirrhosis 
even to such an extent as to produce a large soft tumor, the caput 
Medusce. Not infrequently the walls around the umbilicus are infil- 
trated with carcinoma, occurring secondarily to gastric carcinoma. 
In tuberculous peritonitis, as pointed out by Henry, this infiltration, 
more inflammatory, however, is seen. Removal of such nodules for 
microscopical study often establishes a correct diagnosis of the internal 
disease. 

Glands. Sometimes isolated lymphatic glands are seen in the ab- 
dominal wall. They may be utilized by a microscopical examination 
to confirm any suspicion of malignant disease. 

The Veins. Enlargement of the superficial veins is a common 
accompaniment of cirrhosis of the liver, adhesive pyelophlebitis, and 
of any cause which obstructs the free circulation in the inferior vena 
cava. In order to complete the collateral circulation they may anasto- 
mose with the mammary veins above or the epigastric veins below. 
The caput Medusce has already been described. 

The Movements. (See the Lungs — Dyspnoea.) The movements of 
the abdomen are of respiratory, vascular, gastric, and intestinal origin. 
Much is learned by carefully observing them. 

Respiratory Movements. The upper half of the abdomen swells or 
rises synchronously with inspiration. In enlargement of the abdomen 
and in tumors within the upper half the movement is restricted. In 
paralysis of the diaphragm it falls in with inspiration, reversing the 
normal movement. If such paralysis is limited to one side, as in large 
pleural effusions, the inspiratory collapse is unilateral. In laryngeal 
and tracheal obstruction, inspiratory retraction is noteworthy and its 
extent significant of the amount of obstruction. Respiratory move- 
ment causes the liver to rise and fall. In persons with thin walls, its 
shadow can be seen to descend with inspiration, the extent indicating 
the degree of respiratory expansion, the size and position of the liver. 
Such information is of great value. A tumor connected with the liver 
and an enlarged gall-bladder will move synchronously with respira- 
tion. Other growths are fixed, unless adherent to the liver. Rarely 
an exception is seen in movable right kidney. 

Vascular Movements. They are noted in the median line and usually 
in the upper half of the abdomen. In moderately thin subjects the 
aorta may be the cau^e of such pulsation. (See Epigastric Pulsation.) 
If the pulsation is wide and extends to the right or left of the median 
line, an aneurism may be suspected, or the impulse may be trans- 
mitted to a growth overlying the aorta, as a carcinoma of the stomach. 
Aneurism of the coeliac axis will give rise to a movement near the 
umbilicus and to the right or left of the median line. Pulsation of the 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 729 

liver, of vascular origin, and hence rhythmical with cardiac pulsation 
is seen in the hepatic area in right-sided dilatation of the heart. 

Gastric and Intestinal 3fovements. Peristaltic movement, either of the 
stomach, the large or the small intestine, may be seen through the 
abdominal walls. In gastric dilatation and gastroptosis the waves may 
be seen in rhythmical succession, from left to right, in the centre of 
the abdomen. Their general course may be from the left upper to the 
lower right quadrant. If of the large intestine, the waves are confined 
to the course of this canal ; if in the small intestine, to the region around 
the umbilicus. It is due to obstruction of the pylorus, if gastric, or 
of the lumen of the bowels if intestinal. The application of a cold 
napkin will excite the movements. 

The Shape. In general enlargement the shape is uniform. In 
large accumulations of fat, in women with relaxed abdominal walls, 
the abdomen may be pendulous. In ascites the tissue over the umbil- 
icus may protrude, changing the uniform appearance. Abdominal 
enlargements due to ascites, in women whose abdominal walls have 
previously been relaxed, sometimes assume a peculiar cone-shape ; the 
base corresponding to the plane of the abdomen, the apex rising below 
the umbilicus. This is particularly the case if the patient has had to 
assume the semi-erect position for some time. It is often difficult to 
decide where to tap in such cases. In local enlargements the surface 
is often irregular, the prominences corresponding to the seat of the 
enlargement. The shape changes in hysterical distention. In enlarge- 
ment due to wasting disease of the viscera, as cancer of the retroperi- 
toneal glands, the abdomen retracts in the later stage of the disease, 
causing undue prominence of the viscera affected. 

General Enlargement of the Abdomen. The abdomen 
differs very much in size in different persons, depending not only upon 
the thickness of the fat in the abdominal walls and omentum, but 
upon the calibre of the intestines themselves, which are apt to be much 
distended in those accustomed to eat large meals. In general, the 
belly is more protuberant in infants and children than in adults. 
Enlargement occurs in obesity, and it is often difficult to tell whether 
the excessive deposit of fat in the abdominal walls and omentum 
accounts for the whole enlargement or only serves to mask the presence 
of a tumor. Enlargement of the belly is only a part, though fre- 
quently the most pronounced evidence of obesity ; whereas, in enlarge- 
ments of the abdomen from tumors and ascites, there is usually a 
marked contrast between the size of the abdomen and that of the rest 
of the body. 

Ascites. 

In enlargement from ascites, when the patient is lying upon his back, 
the front of the abdomen is flattened, while the flanks bulge. If he 
turns upon his side, the flank which is uppermost becomes hollowed 
out and the front of the belly is prominent. This is the appearance in 
moderately large effusions which have existed long enough to stretch 
the lateral abdominal muscles. When the effusion is enormous all 
parts of the belly are distended, and the abdomen is barrel-shaped ; 
no change of shape occurs upon change of posture. 



730 SPECIAL DIAGNOSIS. 

Ascites is the accumulation of fluid in the peritoneal cavity. The 
causes may be local or general. Its local origin may be, first, simple, 
cancerous, or tuberculous inflammation of the peritoneum ; second, 
portal obstruction from disease of the liver, as cirrhosis, or disease of the 
portal veins, either from compression or inflammation. Tumors of the 
abdomen are often attended by ascites, particularly solid tumors of the 
ovary. The general causes of ascites are those which give rise to dropsy. 

Physical Signs. (Plate XXXVI.) Inspection. The abdomen is 
uniformily enlarged. The surface is usually smooth. The skin is 
tense if the effusion is large, and linece albicantes may be seen. The 
navel may project. If the ascites is due to liver disease or disease of 
the portal vein, the superficial veins enlarge, although the enlargement 
is sometimes seen when any effusion continues a long period of time. 

Palpation. On palpation fluctuation can usually be detected. Care 
must be taken not to confound the wave of the abdominal walls, 
produced by percussion, with the wave of true fluctuation ; the former 
must be cut off by the hand of an assistant placed vertically in the 
median line. The left hand should be applied firmly against one side 
of the abdomen, while with the right percussion or tapping is gently 
performed at the opposite point. The points selected should be at 
about the level of the fluid. At first the hand should be placed on the 
flank, and if the fluctuation is not revealed, then with each successive 
percussion it should be brought forward toward the median line. 
Sometimes light percussion will yield the sign, at others more firm per- 
cussion must be employed. The faintest tap may be sufficient. In 
order to ascertain the position of solid organs in ascites, dipping is em- 
ployed. This consists in suddenly pressing the tips of the fingers over 
the organ sought for. The fluid is thus displaced and the edge or 
surface of the organ readily felt. 

When the abdomen is percussed in the usual manner there is dulness 
over the fluid. As the fluid gravitates to dependent portions the dul- 
ness is found in these parts. Sometimes the colon gives rise to tym- 
pany in the flanks, as pointed out by Tyson. When the patient is 
lying down, it is in the flanks, and may extend around the lower por- 
tion of the abdomen. If the patient stands up, the dulness may reach 
to the umbilicus in the median line and to the. same level in the mid- 
clavicular line. 

Aspiration In ascites it is important to ascertain the nature of the 
fluid. This can only be done by aspiration. If the fluid is serous, it 
has the characteristics belonging to that fluid. Hemorrhagic effusions 
usually occur in cancer and tuberculosis, although both of these dis- 
eases may occur with clear serum. In ruptured tubal pregnancy the 
effusion is hemorrhagic. In rare cases a chylous, milky fluid is found 
in disease of the lymphatics. In one instance this occurred from per- 
foration of the thoracic duct. Chylous ascites may, however, be due 
to an excessive milk-diet. In other instances it is due to filaria. The 
patient on a mik-diet is often lipaemic, in consequence of which effu- 
sions are made turbid. 

The subjective symptoms are those due to the cause of the ascites and 
to mechanical pressure. 



PLATE XXXV J 




"& : 



Ascites. 



Blue shading shows level of dulness in recumbent posture. Dotted lines 
indicate change of level of fluid in other postures. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 731 

Ascites must be distinguished from enlargement of the abdomen due 
to ovarian tumor, enlargement due to pregnancy, and enlargement due 
to an overdistended bladder. In ovarian tumor the development at 

Fig. 188. 




Ascites. Upper limits of dulness indicated by the dotted line. Umbilicus prominent. 

first takes place to the right or left of the median line. When large 
the signs may be in the central region of the abdomen. The flanks, 
however, are always tympanitic on percussion. On vaginal ex- 

FlG. 189. 




Ascites from sarcoma of ovary. Dislocation of liver and spleen, x is apex beat, not lifted 
because of fallen abdominal organs. 

amination the local disease may be ascertained. A distended bladder 
should always be thought of, and catheterization performed in doubt- 
ful cases. Cysts of the pancreas may be mistaken for ascites, and 



732 SPECIAL DIAGNOSIS. 

large hydatid cysts connected with the liver may simulate an accumu 
lation of fluid in the peritoneal cavity. The history and the appear- 
ance of the fluid on aspiration point to the diagnosis. 

Enlargement from accumulation of gas within the bowels is gen- 
eral, and may attain a very high degree, giving the abdomen a uni- 
form arched appearance resembling a barrel. The diaphragm may be 
pressed upward so far as to interfere seriously with respiration and 
heart-action. In debilitated children the enlargement due to flatulency 
is associated with flaccid abdominal walls, causing lateral and central 
enlargement. Moderate degrees of distention from gas in the intes- 
tines may be the result of eating certain articles of food, such as tur- 
nips or beans. Excessive accumulations are met with in typhoid 
fever ; peritonitis, operative and non-operative ; and in stenosis of the 
colon or rectum from any cause. They are also common in hysteria. 

In the last month or two of pregnancy enlargement of the abdomen 
is general, especially in a woman who has previously borne children. 

General enlargement of the abdomen may be due also to fecal accu- 
mulation, cancer of the peritoneum, to hydatid cyst, and to cancer of the 
bowel. 

It has been observed in children in dilatation of the colon. The dila- 
tation may take place temporarily in constipation with obstruction. In 
rare cases it may become permanent. In such the distention of the 
abdomen is enormous. It often begins in childhood and continues 
through adult life. Congenital obstruction, the eating of oatmeal and 
similar food, with attendant constipation are causes. The bowels are 
constipated. " The constipation may continue for several weeks, during 
which period there is increasing dulness in the tract of the colon, with 

Fig. 190. 




Case of dilatation of colon. (Griffith ) 



fecal tumors distinguished by palpation. This condition is relieved 
by diarrhoea, which may continue for two or three days, during which 
enormous amounts of feces are passed. It may be preceded by vomit- 
ing of a fecal character. After the bowels are open the distention 
continues, the dulness being replaced by tympany. The abdomen was 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 733 

uniformly enlarged in Hughes 7 and Osier's cases. Coils of the intes- 
tine, with waves of peristalsis, were seen through the thin abdominal 
Avails. Formad's patient was an adult. It must be remembered, as 
described on page 729, intestinal peristalsis is observed in constriction 
of the bowels. The motion of the intestine above the seat of stricture 
is wave-like or worm-like, and the bowel itself dilated. 

From a consideration of the recorded cases of so-called idiopathic 
dilatation of the colon, Treves believes that, although enormous dilata- 
tion of the large intestine may undoubtedly occur in adults indepen- 
dently of mechanical obstruction, in children it is probably due to 
congenital defects in the terminal part of the bowel. 

Enlargement of the abdomen simulating ascites may be due to retro- 
peritoneal and peritoneal lipomata. Fluctuation even may be detected, 
but repeated puncture fails to secure fluid ; the negative aspiration 
should always suggest lipoma. This is all the more likely if the en- 
larged abdomen is due to a slowly growing tumor, which is probably 
more visible on one side than the other, but wdiich causes little if any 
general disturbance except progressive emaciation, dyspnoea, and some- 
times oedema of the legs. The tumor is usually crossed by a portion 
of the intestine. 

Other causes of abdominal enlargement are diseases of the liver and 
gall- bladder. When these are enlarged a local swelling may be de- 
tected in the right upper quadrant ; but when they attain very large 
dimensions, as happens not infrequently in cancer, amyloid disease, 
and hydatid liver, inspection may be able to detect only general en- 
largement, with small prominences corresponding with cancerous nod- 
ules or small cysts. 

Splenic enlargements, which attain the greatest size, are from leu- 
kaemia or chronic malarial poisoning, and are usually visible only as 
general enlargements of the belly. There may, however, be greater 
prominence over the lower left ribs and in the left upper quadrant 
posteriorly. 

In diseases of the kidney producing great enlargement there is usu- 
ally visible a prominence in the lateral and lumbar region of the side 
corresponding with the kidney involved, unless there is considerable 
emaciation ; anteriorly the enlargement, if any be visible, usually 
appears to be general. 

Enlargements of the abdomen which begin in the lower quadrants 
are usually of pelvic origin. The most common are those due to preg- 
nancy, retroperitoneal sarcoma, cysts of the ovary or parovarium, fibroids 
and fibro-cysts of the uterus, and abscesses or effusions (chronic perito- 
nitis). A greatly distended bladder may cause confusion ; it is a good 
rule to be sure that the bladder is empty, by having a catheter passed 
before proceeding further with the examination. 

Local Enlargement or Tumors of the Abdomen. In the 
space below the xiphoid cartilage and between the ribs (epigastrium) 
local enlargements may be due to a distended or dilated stomach or to 
a tumor of the pylorus, which is almost always cancerous. Promi- 
nence in this region is seen in large eaters. But enlargement in this 
region is sometimes due to cysts, sclerosis or cancer of the pancreas, 



734 SPECIAL DIAGNOSIS. 

to aneurisms, to cancer of the large intestine or tumor of the left lobe 
of the liver. It is in this region or to the left of the median line and 
nearer the umbilicus that the effusions into the lesser peritoneal cavity 
are found. 

A rigid rectus muscle is capable of simulating a tumor. Likewise, 
in hysterical subjects, rigid abdominal muscles, with tympanites, give 
rise to a swelling known as " phantom tumor." Such swellings are 
less constant in shape and character than genuine tumors, and although 
dull on percussion appear more superficial ; they sometimes disappear 
under friction with the hand, and certainly under full anaesthesia ; the 
stigmata of hysteria are present. 

Enlargements in the right upper quadrant (right hypochondrium) 
are most frequently due to diseases of the liver (g. v.) and to affections 
of the gall-bladder. Less frequently, a much enlarged kidney or a 
hydronephrosis causes swelling in this region. The differential diag- 
nosis is made by the history of the case and by noting the direction in 
which the tumor has grown, by examination of the urine, and by the 
relation which the ascending colon bears to the tumor ; kidney tumors 
carry it in front of them as they grow ; hence, their dulness is obscured 
by the superficial tympany of the colon. 

Primary malignant disease of the suprarenal bodies — a rare affec- 
tion — is often attended by a tumor in the upper abdomen (Rolleston 
and Marks, American Journal of the Medical Sciences, 1898.) The 
clinical picture is not one of Addison's disease even when both the 
organs are invaded. Some of the symptoms occur partially, as pig- 
mentation, vomiting, asthenia, pain in the back. The growth extends 
forward, and resembles in many respects renal tumor. It also, how- 
ever, may resemble tumors of the liver, enlarged gall-bladder, or pan- 
creatic cyst. 

Enlargement in the right lower quadrant (right iliac region) is most 
frequently due to affections of the caecum and appendix, to tumors of 
the ovary, and to pelvic abscesses. 

The diseases of the ccecum and appendix causing enlargement in the 
right iliac fossa are fecal accumulation, typhlitis, fecal abscess, peri- 
typhlitic abscess, carcinoma, and stricture of the ileo-caecal valve. 

The diseases of the ovaries and tubes causing enlargement in this 
region are ovarian tumors, cysts of the broad ligament, pelvic abscess 
(usually tubal in origin), and extra-uterine pregnancy. 

Other affections which need to be considered are tubercular peri- 
tonitis, acute and chronic, and enlarged or movable kidney. 

Enlargement in the left upper quadrant (left hypochondriac region) 
is due to dilatation or carcinoma of the stomach ; enlargement of the 
spleen, movable kidney, or tumors of the kidneys, and effusion in the 
lesser peritoneal cavity. Enlargement in the left lower quadrant (left 
iliac region) is due to tumors (cancerous) of the sigmoid flexure and to 
the tumor due to volvulus, and to the same causes of enlargement of 
the right side which are possible on the left. 

Enlargement about the centre of the abdomen (umbilical region) may 
be due to umbilical hernia, to a floating kidney, spleen, or liver, or to 
tubercular disease of the omentum or mesenteric glands. It is seen 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 735 

in retroperitoneal sarcoma. It is seen in cases of dilatation after a full 
meal. This region is frequently enlarged, in conjunction with a more 
prominent swelling extending from the sternum, in cancer of the stom- 
ach ; and from the ribs on the right in cancer of the liver or gall- 
bladder, or other diseases of these viscera ; from the ribs on the left, in 
effusions into the lesser peritoneal cavity, disease of the pancreas or 
the spleen. 

Undue projection of the vertebrce must not be mistaken for tumors. 

Enlargement above the pubis (hypogastric region) is due most fre- 
quently to enlargement of the uterus from pregnancy, fibroid tumors, 
or fibro-cysts, or to distention of the bladder ; but it is also common 
in gastric dilatation and gastroptosis ; flattening of the upper half is 
then seen, and the lesser curvature is then made out. 

Enlargement in the lateral regions and behind {lumbar region) may 
occur in malignant tumors of the kidney, in hydronephrosis and 
pyonephrosis, in perinephritic abscess, and in renal cysts of large size. 
Usually renal enlargements of any kind are not observed behind, 
however. It may also, in the left side, be due to perigastric sub- 
diaphragmatic abscess and to enlargement and displacement of the 
spleen. On the right side the cause may be enlargement of the liver, 
or a hydatid cyst, or a retroperitoneal sarcoma. 

Diminution in Size. The abdomen is diminished in size in 
wasting diseases, or such as result in insufficient food being taken. 
This class comprises cancer of the oesophagus and stomach, chronic 
lead-poisoning, anorexia nervosa, and chronic diarrhoea and tubercu- 
losis of childhood. In the second stage of tubercular meningitis in 
children there is retraction of the abdomen. The wasting of the sub- 
cutaneous and the omental fat and atrophy of the abdominal organs 
cause the abdomen to be concave or scaphoid. 

Palpation and Percussion of the Abdomen. Palpation and per- 
cussion in diseases of the abdomen may be discussed together. 

Position of Patient. Generally the best position is the recumbent 
one, because it admits of examination without too great exposure, and 
because in that position the abdominal muscles are partly relaxed. 
When the muscles need to be still further relaxed the patient should 
lie upon the back, with the head and thorax partly elevated and the 
knees drawn up. In certain obscure tumors much can be learned by 
having the patient rest on the hands and knees, or assume a knee- 
chest position. By this means we can determine if the pulsation is 
due to aneurism or to a tumor. The latter falls away from the vessels, 
and hence pulsation is lessened thereby in the knee-chest position. 
A tumor surrounded by coils of intestine may thus become more pal- 
pable. A good plan to secure relaxation for palpation of the liver 
and spleen is to have the patient sit on a chair with the body leaning 
forward ; then flex the thighs, supporting the feet on a stool or the 
rung of another chair. 

Method. The examining hand should be warm, as the application 
of a cold hand throws the abdominal muscles into involuntary contrac- 
tion. By grasping the abdominal walls between the thumb and fingers 
their thickness and the relative proportion of fat can be estimated. 



736 SPECIAL DIAGNOSIS. 

So, too, the presence or absence of oedema of the skin can be readily 
detected. This oedema is general, but is especially marked in the 
lateral and posterior portions of the abdomen. Relaxed abdominal 
walls occur after dropsy and pregnancy. Redundant skin remains 
in folds when pinched up. This is particularly so in abdominal 
cancer. 

When it is desired to explore deeply the patient should be instructed 
to breathe with the mouth open, and the examining hand pressed 
firmly in during respiration, and held there, if need be, during several 
long respirations. The palm of the hand should be laid upon the sur- 
face ; after the muscles are relaxed the flexed fingers may be used to 
palpate. The same procedure is adopted when we desire to get the 
percussion-note of a body lying deep in the abdomen : the finger is 
pressed firmly and deeply in, and then percussed. In this way any 
superficial resonance due to overlying intestine is largely eliminated. 

When palpating to determine the lower edge of the liver or spleen 
the palmar surface of the fingers is pressed into the abdomen at differ- 
ent levels from below upward until the edge is felt. The edge of 
the right lobe of the liver in its normal position extends to the margin 
of the ribs. It may be detected by pressing the fingers in as de- 
scribed and having the patient take a long breath. 

By palpation the information obtained by inspection is confirmed ; 
the character of the abdominal walls and of swellings is determined ; 
the precise location of pain is ascertained ; the condition at the hernial 
rings and the movability of tumors are investigated. The condition 
of the integument should first be determined. Passing the hand gently 
over it is sufficient to decide whether it is normal, smooth and elastic, 
or harsh and dry. Any marked unevenness, such as is produced by 
umbilical and inguinal hernia, by stria?, or by large tumors of the 
pylorus, or cancerous nodules, and hydatid cysts of the liver, can 
readily be detected. The degree of tension of the abdominal walls is 
easily appreciated. It is increased, of course, in all forms of great en- 
largement, but not equally ; some persons are so sensitive to touch 
that any attempt at palpation throws the abdominal muscles into such 
rigid contraction that examination is impossible. Rigidity of the 
abdominal walls may be the only sign of acute peritonitis. It is com- 
mon in local peritonitis. The recti muscles contract quickly on hurried 
palpation. Local contractions point to inflammation underneath. In 
tuberculous peritonitis we see distention with board-like rigidity or 
preternatural hardness. The term carreau is used by the French for 
this condition. Peritoneal friction may be detected most frequently 
over the liver and in chronic peritonitis. 

Palpation and Percussion of the Lower Quadrants. On 
the right side, the groups of affections connected with the caecum and 
appendix, the uterine appendages, and the peritoneum, which cause 
enlargement in this region, have been mentioned already under local 
inspection of the abdomen. Palpation and percussion, however, are 
the methods which afford the most exact information of their physical 
characteristics, and, with the clinical history, enable us to distinguish 
one from the other. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 737 

Diseases of the Appendix and Cazcum. The information supplied by 
palpation and percussion in perforation of the appendix will depend 
upon the rapidity with which perforation has supervened and upon 
the stage at which the examination is made. 

Generally speaking, after the sudden onset of pain in the right iliac 
fossa, in a person previously in good health, there is tenderness on 
palpation in that region. This tenderness is first localized, but may 
spread with great rapidity over the whole abdomen. Or the tender- 
ness may at first be general, and subsequently become localized over the 
appendix. Subsequently, the tension in the part is increased, the over- 
lying abdominal muscles are rigid (spasm) and firm, and the percussion- 
resonance impaired. Examination with the finger in the rectum may 
discover a tense, swollen appendix, or a tumor in the pelvis. 

Bat the disease may be fulminating in character, perforation being 
followed by the rapid development of peritonitis, with collapse, so 
that when the patient is seen there will be no more tenderness over 
one part of the abdomen than over another. 

Again, the appendix may be subject to repeated attacks of inflam- 
mation without perforation, but with the development of local peri- 
tonitis. There is increased thickness in the region of the caecum, 
tenderness, diminished resonance, and increased resistance to the 
percussed finger. Sometimes an enlarged and hardened appendix can 
be made out by palpation, both during an attack and in the intervals. 

In still other cases, of slower development, a distinct perityphlitic 
abscess develops. In addition to local pain and tenderness a swelling 
appears above Poupart's ligament. The skin over it becomes brawny 
and pits on pressure with the finger-tips. The tumor is dull on percus- 
sion, and on palpation obscure deep-seated fluctuation may be secured. 
A fluctuating tumor may also be made out by rectal examination with 
the finger. 

In fecal impaction of the ccecum a tumor forms, following the course 
of the caecum, and directed upward from Poupart's ligament. It is 
usually oblong and rounded, and may appear uneven or lumpy on 
closer palpation ; it is not tender unless the caecum itself becomes in- 
flamed. It has a doughy consistency. Fecal tumors give rise to 
some distention of the abdomen. To distinguish these tumors from 
solid growths, Gersuny calls attention to the "adhesive symptom." 
If strong pressure is slowly made with the finger tips on the tumor, 
and then the pressure be withdrawn gradually and the hand removed 
from the abdomen, a peculiar sensation due to the separation of the 
intestinal mucous membrane from the fecal matter is transmitted to 
the hand. If the feces are dry and hard, the sensation may not be 
observed until an oil enema is used. When the feces are soft natur- 
ally or artificially, the tissues remain depressed and only gradually 
separate from the mass and return to their normal position. Slowness 
of the separation of the abdominal walls from the tumor is also charac- 
teristic of the fecal accumulation. The diagnosis is made by the situ- 
ation and character of the tumor, and the absence of pain, tenderness, 
and constitutional symptoms, and by its disappearance under the influ- 
ence of purgatives. 

47 



738 SPECIAL DIAGNOSIS. 

If the impaction causes a localized colitis, or so-called typhlitis, the 
tumor is tense, tender, and painful, dull on percussion, the dulness 
being sharply limited by the boundaries of the caecum. 

Appendicitis. 

This is by far the most important affection of the intestinal tract. 
It is of frequent occurrence compared with intestinal obstruction, and, 
if recognized, is amenable to relief in a very large percentage of the 
cases ; whereas intestinal obstruction is more frequently fatal. We 
see twenty-five cases, at least, of appendicitis in all its forms to one 
case of any form of obstruction. Its importance, therefore, is readily 
recognized. Appendicitis occurs most frequently in the young — in 
the large proportion of cases under thirty. I have seen it as early as 
two years of age, although from the fifteenth to the thirtieth year it 
is more frequent than at any other period. The symptoms vary, but 
clinically may be divided into those of appendicitis without perforation 
and appendicitis with perforation. Appendicitis without perforation 
is characterized by relapses, and is known also as recurring appendicitis. 

Appendicitis without Perforation. Cases of catarrhal appen- 
dicitis probably occur, although I am not prepared to say that 
catarrhal inflammation of the appendix gives rise to marked local 
symptoms, for in cases on the post-mortem table in which the lesions 
of catarrh were found there had not been any symptoms during life, 
due either to intestinal catarrh or to any symptoms pointing to appen- 
dicitis in any form. Moreover, many cases in which the attacks of 
appendicitis had at first been slight, finally developed into appendicitis 
with perforation. In the milder cases, if operative measures are re- 
sorted to during the intervals between the attacks, the appendix is 
always found to contain a fluid loaded with micro-organisms which 
are capable of causing purulent inflammation, as the staphylococcus or, 
streptococcus. Clinically, therefore, all forms of appendicitis should 
be considered infectious, Avith, on the one hand, escape of the contents 
into the bowel, and natural relief of the symptoms ; or, on the other, 
complete obstruction with perforation. After removal of the appendix 
in cases of recurring appendicitis, I have always found pus or a muco- 
purulent material which was charged with streptococci or staphylococci, 
as well as the bacillus coli communis, natural to the intestinal canal 
in this region. 

Symptoms of the Attack. After exposure to cold rarely, fre- 
quently after an indiscretion in diet, the patient is seized with pain, 
referred to the right lower quadrant of the abdomen. It is paroxysmal 
in character, increasing in intensity, and may be complained of as 
colicky. The pain is usually such as to require the patient to take to 
bed and attempt to secure relief by local applications. The severity 
of the pain may be so slight that the patient pays but little attention 
to it. He may even go about his business during the time and seek 
professional advice at the office of a physician. Such cases as these 
are attributed to ordinary cholera morbus or intestinal indigestion. 
The attack may be only moderately severe, particularly if there is 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 739 

diarrhoea. With the onset of the pain vomiting usually occurs. The 
bowels may be open or they may be confined. Vomiting may not 
occur if there is diarrhoea. It is usually attended by some nausea, 
although this is not marked. The vomiting is complete, there is no 
retching. It occurs at intervals, between which there is comparative 
comfort. The contents of the stomach are ejected, and then mucus. 
If the patients are to get well, vomiting does not return unless ex- 
cited by food. If peritonitis supervenes, vomiting returns in the course 
of two or three days. If in bed, the patient lies on his back with 
his right leg flexed. 

Even with a mild degree of pain the skin is hot and temperature 
slightly raised. In the cases in which the pain is more severe the 
general reaction is greater. The temperature rises rapidly to 102° to 
103°. The skin is hot and dry, the face flushed. The pulse in a 
young adult rises to 90 and 95. It is full and strong. On account 
of the pain there is some restlessness. In some cases the patient com- 
plains more of the fever than of the pain after its first severity has 
subsided. The tongue is coated ; appetite is lost. 

On physical examination the area Avhich was the seat of pain is 
found to be tender. When examined with the tip of the finger press- 
ing firmly, a point of more marked tenderness can usually be found 
on a line midway between the anterior superior spine of the ilium and 
the umbilicus. It is known as McBurney's point, and is most charac- 
teristic. It indicates the site of the diseased appendix. The swollen 
tender appendix may occasionally be palpable. On inspection the 
affected area is slightly or may be considerably enlarged. Comparison 
must be made with the opposite side. It will be seen that the usual 
depression in front of the anterior spine, or the cavity toward the loin, 
is not so deep as on the opposite side. In front the surface may be 
even with the plane of the ilium. On palpation, in addition to ten- 
derness and pain at the point previously indicated, fulness and en- 
largement can be distinguished. There is resistance to pressure and 
more or less rigidity of the abdominal muscles. On careful measure- 
ment the semi-circumference will be found in most instances to be 
larger than the semi-circumference of the opposite side. When 
bimanual palpation is performed, the left hand being placed in the 
loin behind and the right over the abdominal surface, resistance, in- 
duration, and rigidity can more easily be detected. On percussion 
there is change in the note compared with that of the opposite side, 
and change in the percussion-note during the course of the disease. 
This is particularly the case if the symptoms go on to perforation. 
On careful deep percussion a dull tympanitic tone is elicited, or a 
distinct area of dulness can be mapped out, but in some instances the 
distended caecum yields tympany, which is greater than on the opposite 
side. 

The pain is usually referred to the region above mentioned. The 
pain may be in the lower quadrant on the left side instead of the right. 
It is seen in those cases in which the appendix normally dips into the 
pelvis. It may also be referred to the bladder or genitals, and be 
attended with vesical tenesmus and frequent micturition. The char- 



740 SPECIAL DIAGNOSIS. 

acter of the pain and the bladder symptoms are such as to simulate an 
attack of renal colic, with the passage of sand. On account of the 
locality of the pain it may be attributed to the Fallopian tube or ovary, 
and thought to be due either to pain on account of disease of these 
organs or to dysmenorrhea. It is not likely to be mistaken for the 
pain of dysmenorrhea if the patient is subject to pain at the usual 
monthly period. If, however, the physiological and the pathological 
affection should take place at the same time, or the latter occur about 
the time of the monthly period, a mistake in diagnosis may occur, 
particularly as increased abdominal pain may cause a uterine discharge. 
The occurrence of fever would exclude dysmenorrhea in cases in 
which this symptom was present. The pain and leg-flexion simulate 
hip-joint disease. 

After the first twenty-four hours, during which the above-mentioned 
symptoms described take place, the fever continues. There is anorexia, 
but vomiting occurs only at long intervals if at all. The local symp- 
toms continue, although modified usually by methods of treatment which 
are applied. Both general and local symptoms frequently subside after 
a free movement of the bowels, which occasionally takes place sponta- 
neously. In other cases constipation continues a week or ten days, 
and even over a longer period. 

After five or six days at the farthest the fever subsides, the local 
distention lessens, the paroxysms of pain disappear, and convalescence 
ensues. There may, however, be localized tenderness for a consider- 
able period of time, and diarrhea, or at least two or three evacuations 
each day, for a week or more. In rare instances peritonitis supervenes 
without the occurrence of perforation. Its onset under these circum- 
stances is gradual, bat the symptoms are like those of peritonitis 
under other circumstances. Infection takes place directly through the 
appendix. 

When the fever continues, with mild diarrhea, intestinal pain, and 
flatulency, the case may be mistaken for typhoid fever. The tempera- 
ture is, however, more remittent in character in appendicitis, and the 
diarrhea is not characteristic of typhoid fever. The eruption of 
typhoid fever does not occur, the spleen is not enlarged, and the symp- 
toms of the typhoid state do not ensue. The diazo-reaction, the 
bacteriological examination of the stools, and the serum test, may aid 
in forming a conclusion. 

Recurrent Appendicitis. Frequent attacks of mild appendicitis 
occur ; they may occur as frequently as every three months, or the 
interval may be as long as a year. The attacks are similar to the 
attacks just described, although the duration is shorter. The local 
symptoms in some instances are more marked, because there has been 
a localized peritonitis previously. The induration is greater, and dul- 
ness more marked. In some instances the attacks are comparatively 
mild, continuing but twenty-four hours, and are described as attacks 
of colic. Often they have been treated by the patient himself, by 
household remedies alone. The patient spends a night in agony, with 
cramps, but the next day follows his usual habits. It is possible 
that there has been no fever with the attacks, but in all cases of 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 741 

recurrent appendicitis which I have seen, fever, although often slight, 
has been a constant accompaniment. 

Appendicitis with Perforation. Before perforation takes place 
the patient may have had symptoms of the mildest form of appendi- 
citis for two or three clays, or they may have extended over a long 
period of time, without any symptoms except colicky pain. As obser- 
vations are not made, the presence of fever cannot in such a case be 
utilized as a diagnostic feature. The perforation may take place early 
in the course of an acute attack, and result in localized peritonitis and 
abscess, or in diffuse peritonitis. If the latter, after the characteristic 
symptoms of appendicitis the symptoms of intense peritonitis set in. The 
abdomen rapidly becomes distended, the characteristic vomiting ensues, 
and collapse develops. Perforation under these circumstances has 
occurred within the first twenty-four or at most within forty-eight hours. 
Local inflammation about the appendix does not take place, and the local 
signs of an inflammatory tumor are not present, although tenderness 
at the special point can be elicited. 

Abscess. If the perforation is more gradual, and there has been time 
for the occurrence of local inflammation about the appendix, by which 
pus is prevented from infecting the general peritoneum, or if perforation 
takes place behind, in the connective tissue which surrounds the mass, 
in which situation there is always inflammation, the local signs of ab- 
scess or inflammatory tumor occur. There is swelling of the affected 
side ; the normal outline is effaced. The area is indurated, and the 
early pronounced rigidity gradually gives way to a boggy sensation, 
with the appearance of cedema of the skin. This can be elicited by 
pressure over parts that are hard and resisting, as the spine of the 

Fig. 191. 




Acute appendicitis, with perforation and abscess. Female, set 8. Operation on seventh day. 

ilium. Fluctuation can often be detected by bimanual palpation. 
Dulness is found, although in some instances it may be very slight, 
there being scarcely an appreciable change in pitch. Both light and 
deep percussion must be performed, and compared with the results of 



742 SPECIAL DIAGNOSIS. 

percussion in the opposite region. Palpatory percussion may alone 
indicate the departure from normal. Examination per rectum may 
yield much information. An induration may be felt about the brim 
of the pelvis or the rectal fossa, which fluctuates and may eventually 
soften. With the finger in the rectum, and pressure above, better 
results may be obtained. If the symptoms of peritonitis do not arise, 
or rapid infection of the system take place, the signs of abscess become 
more and more marked. The surface becomes reddened, and point- 
ing may take place toward the groin or opposite the spine of the 
ilium. Sometimes the swelling increases in the direction of the loin, 
and the abscess may point in that situation. 

As the abscess develops the general symptoms change. They now 
become the symptoms of suppuration. The fever is remitting or inter- 
mitting. There may be chills. Sweats are common, and there are 
loss of appetite and diarrhoea. Until recently it was customary to see 
abscess develop in some other situation, or symptoms occur from bur- 
rowing of the pus in various directions. It may extend upward along 
the back of the colon, underneath the diaphragm, and thence to the 
pleura and lung, and be expectorated. The abscess may open into the 
rectum or into the bladder. If the local inflammation is virulent, 
even if peritonitis has not taken place, the symptoms of septicemia 
may rapidly ensue. This sometimes occurs quite early in the disease. 
There may be vomiting and septic diarrhoea, and slight delirium at 
night. An excessively rapid and feeble pulse is seen ; in one instance 
it was irregular. Extreme prostration ensues, followed by symptoms 
of the typhoid state. 

Gangrenous appendicitis is most treacherous. The early symptoms 
are like an acute attack ; all symptoms then subside. Unless the 
temperature is taken or the physical examination is very painstaking, 
the patient is allowed to get up. The course may be afebrile. In a 
few days or a week an abscess forms about the slough, and then the 
usual phenomena of suppuration set in ; or perforation may occur. 

It is clear that in cases of appendicitis we must attempt to recog- 
nize : (1) The inflammation before perforation has taken place ; (2) the 
occurrence of perforation ; (3) the occurrence of peritonitis due to 
either of the two conditions ; (4) the occurrence of abscess (paratyph- 
litis and perityphlitis) ; and (5) the occurrence of septicaemia. 

Typhlitis is an inflammation of the caecum due to accumulation of 
fecal or foreign substances. The inflammation may remain as a local- 
ized enteritis, or may be followed by ulceration. In the majority of 
cases the ulceration is due to pressure by the contained foreign mate- 
rial or feces. The inflammation occurs in early life usually. The 
patients have been subject to constipation. The attack may follow 
some error in diet. There are pain in the right iliac fossa, constipa- 
tion, and nausea. Moderate fever develops. On examination there 
is fulness in the right iliac region, and the right thigh may be flexed, 
the caecal region is tender to pressure, and a doughy, sausage-shaped 
tumor may be outlined. The more severe symptoms last two or three 
days. Local tenderness may continue a week or even longer. The 
tumor gradually disappears. If ulceration takes place, inflammation 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 743 

about the caecum ensues. An abscess forms gradually in the flank. 
Perityphlitis is the term applied to this secondary abscess, although, 
as the term has been confused with paratyphlitis, it had better not 
be used in this connection. 

Abscess about the head of the caecum is due (1) to appendicitis, of 
which sufficient mention has been made ; (2) to perforation of the 
caecum, on account of typhlitis ; (3) to perforation, on account of cancer 
of the intestine ; (4) abscess secondary to kidney disease, perinephritic 
abscess ; (5) to abscess secondary to disease of the vertebrae. The 
physical signs are those of abscess due to perforation of the appendix. 
The symptoms are the local symptoms of abscess and the general symp- 
toms of suppuration. 

Fecal abscess, arising from ulceration of the colon, may be sus- 
pected, according to Fenwick, when there is a localized abdominal 
swelling, immovable in respiration or by a moderate amount of pressure 
with the fingers, the size and shape being altered when diarrhoea 
occurs, and when percussion over the tumor gives a tympanitic or a 
more forcible stroke, a dull sound, or when an emphysematous sensa- 
tion is communicated to the fingers. 

Pericecal abscess follows the stercoral typhlitis which occurs as the 
result of cancer in the course of the large intestine. The history of the 
case points to the true nature of the disease. Abscess may occur 
behind the caecum in cases of caries of the vertebrae and in some rare 
instances of empyema in which the pus has dissected downward. 

Appendicitis must be distinguished from perinephritic abscess and 
the abscess which follows perforation of the intestine or caecum at this 
point. Perinephritis can scarcely be distinguished unless there has 
been a previous history of renal calculus and pronounced evidence of 
disease of that organ preceding the formation of the abscess. 

Hip-joint disease must be distinguished from appendicitis. The leg 
is flexed, the patient complains of pain about the region of the hip ; 
unless careful observation has been made in the beginning of the 
attack, the early march of appendicitis may not be recognized. The 
two are confounded after abscess-formation. The flexed leg of appen- 
dicitis can be extended under ether, and examination then shows the 
joint to be free from disease. 

Fenwick says that acute tubercular peritonitis may be confounded 
with perforation of the appendix. In both there may be pain and 
tenderness in the hypogastrium, dulness on percussion, and fever. 
In tubercular peritonitis the onset is more gradual, the pain and ten- 
derness more general, and there is no distinct tumor or increased tension 
in the hypogastrium. If there is dulness on percussion, the line gen- 
erally varies with the position of the patient. Diarrhoea is urgent, 
and there are, in most cases, some signs of consolidation of the lungs. 
The absence of tumor in the right iliac region and in front of the 
rectum is the chief point of distinction ; for when perforation occurs 
in phthisical subjects there is generally very slight pain, and severe 
diarrhoea is often the only prominent symptom. The appendicitis 
itself may be of tuberculous origin, as in several cases reported by the 
writer. 



744 SPECIAL DIAGNOSIS. 

Returning to palpation and percussion of the lower quadrants, we 
find in intussusception a tumor, often detected in the right lower quad- 
rant or to the right of the navel. It is generally distinct, of the shape 
of the bowel, not very tender, and harder than the tumor of appendic- 
ular inflammation. The diagnosis from the latter is made by the 
difference in the character of the tumor, by the pain being colicky and 
recurring in paroxysms, by vomiting and constipation being more 
marked, and by the tenesmus and passage of blood and mucus from 
the bowel. The last-named symptom and the tumor, with a constant 
desire to defecate, are the most characteristic features of intussuscep- 
tion. A tumor may be detected within the rectum by digital explora- 
tion, if the intussusception is low down. There may be distinct 
hemorrhage, or the passage of the invaginated portion of the bowel per 
rectum. Intussusception is the most frequent cause of intestinal ob- 
struction in infants and young children. It occurs nearly twice as 
often in males as in females. Stercoraceous vomiting is not so common 
as in other forms of acute obstruction of the bowel. 

In pelvic abscess a swelling sometimes makes its appearance on the 
right side, above Poupart's ligament. It is, perhaps, situated more 
toward the median line than perityphlitic abscess, and it is less defined 
than the tumor of typhlitis ; but the diagnosis from these affections 
must be made by the history, which is usually that of an antecedent 
salpingitis or of previous abortion or miscarriage. Vaginal examina- 
tion discovers that palpation of the uterus causes pain ; that the 
uterus is fixed, instead of being freely movable, and that the pelvis 
is blocked up by an exudate on the affected side. 

In pelvic hcematocele a tumor may form in the lower half of one of 
the lower quadrants. It is distinguished from appendicitis, perityph- 
litic abscess, and pelvic abscess by the absence of fever and constitu- 
tional signs of suppuration ; from perityphlitic and pelvic abscess by 
its sudden onset, probably at a menstrual period ; by the less degree 
of tenderness, and by the anaemia and collapse which follow its appear- 
ance. It is almost invariably the result of a ruptured extra-uterine 
pregnancy. Hence, it may be preceded by the passage of decidua and 
the objective signs of pregnancy. It is distinguished from pelvic 
abscess by its occurrence in a woman without antecedent tubal or 
uterine disease, and by the less degree of tenderness of the uterus and 
relative absence of fixation. 

In stricture of the ileo-ccecal valve due to cancer there is frequently a 
tumor in the right lower quadrant, between the umbilicus and anterior 
superior spinous process of the ilium, or between the latter and the 
ribs. The diagnosis is made by noting the fact that the tumor has 
developed gradually, that the patient has suffered with colicky pain, 
vomiting, and constipation, possibly preceded by diarrhoea, and that 
peristaltic movements of the intestines can readily be seen through the 
abdominal walls. The abdomen at the site of the tumor is somewhat 
distended. The tumor itself is irregular and tender, and is dull on 
percussion. 

The disease is very rare, and is said by Fenwick to be more common 
in women from twenty to forty years of age. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM 745 

In tumors of the right ovary there is at first a gradual enlargement 
in the right groin, unaccompanied by pain, fever, or impairment of 
health until the tumor has attained considerable size. They are usually 
cystic, and fluctuation can be obtained. The tumor is dull, and by 
bimanual examination, with the fingers of one hand in the vagina, the 
tumor can be traced into the broad ligament, and the displacement of 
the uterus which it occasions made out. The cystic ovarian tumors 
grow from the starting-point in the direction of an axis diagonally 
toward the median line. There is dulness in front of the abdomen 
and a clear percussion-note or tympany in the flanks. (Fig. 192.) 

Fig. 192. 




Position of an ovarian tumor of the right side, in various stages of enlargement. The shading 
indicates the percussion-dulness in ovarian dropsy of moderate extent ; the umbilical region is dull 
from the presence of fluid, and the flanks remain clear. The outer circle shows a further extent 
which the dulness may reach in ovarian dropsy. (Bright.) 



Palpation and Percussion in the Left Lower Quadrant. 
Enlargements in this region are due most frequently in women to 
ovarian tumors, pelvic abscess, pelvic hematocele, and fibroids of the 
uterus, the diagnostic points of which have been referred to already 
under palpation and percussion of the right iliac region. In addition 
to the affections named, enlargements are occasionally met with from 
fecal accumulations in the flexure of the colon, cancer of the descending 
colon, tubercular peritonitis, and enlargements or displacements of the 
spleen and kidney (q. v.). Fecal abscess also may occur here, and the 
tumor of intussusception may be detected on the left side. 

Palpation and Percussion above the Pubis. Enlargements 
in this region may be due to fibroid tumors of the womb. They occur 
most frequently in sterile women, and are accompanied usually by 
hemorrhage. Bimanual examination of the uterus will reveal an un- 
evenness of surface of the womb if the tumor is external, and passage of 
the sound will detect any growth projecting into the cavity of the womb. 

The enlargement may be due to a distended bladder. It is a good 
rule always to be sure that this viscus is empty before beginning an 
examination. 

In acute tubercular peritonitis a swelling may develop in this region. 
It appears gradually, is diffused and free from tenderness, but is pre- 



746 SPECIAL DIAGNOSIS. 

ceded by pain and fever. There is no palpable tumor, but the percus- 
sion-note is dull and the tension is increased. Moreover, the level of 
dulness is apt to vary with change of posture. The general health is 
markedly affected, loss of flesh is rapid, and diarrhoea and sweats are 
common. A focus of disease may be discovered in the lungs. 

Palpation and Percussion of the Eegion below the Ster- 
num. Enlargement in this region is most frequently due to affections 
of the stomach (q. v.). It is not uncommon, however, to find here a 
cancerous nodule projecting from the surface of the liver, or a hydatid 
cyst of the same organ. The diagnosis must be made by determining, 
with the aid of palpation and percussion, whether the tumor is con- 
tinuous with the liver, the effect of respiration upon it, and its apparent 
depth from the surface, tenderness, fluctuation, etc., and by a study of 
the subjective symptoms pointing to disease of the stomach or liver. 
(See Diseases of the Liver.) 

Much more rarely enlargement here may be from tumor of the pan- 
creas, such as cyst, abscess, or cancer. According to the studies of 
Fitz, the former is marked by deep-seated colicky pain occurring in 
paroxysms, by discharges from the bowels of matter resembling saliva, 
by the detection of fat in the stools and sugar in the urine, by saliva- 
tion, and by the occurrence of jaundice. 

Cancer of the pancreas is recognized by the detection of a painful 
tumor in the epigastrium. The pain is not aggravated by the taking 
of food, but is said to be increased by the erect posture. The bowels 
are constipated, and the stools may or may not be fatty. Emaciation 
is progressive, as in all cancerous affections, and in the last stages 
there may be occasional vomiting and persistent jaundice. 

Palpation and percussion of the upper right quadrant is 
limited largely to an investigation of changes in the liver and gall- 
bladder, and is discussed in the section devoted to them. 

Palpation and Percussion of the Upper Left Quadrant. 
Enlargement in this region is generally due to disease of the spleen 
(q. v.). It may be due to fecal accumulation in the left transverse and 
descending colon. This condition is recognized by the painlessness 
and doughy consistence of the tumor, and by careful inquiry as to the 
condition of the bowels. Constipation will, of course, exist, but both 
patient and physician may be misled by apparent diarrhoea, or even 
dysentery ; there will be fluid or semi-fluid dejections mingled with 
scybala, and sometimes mucus and blood. 

An interesting cause of swelling in this region, and in the lumbar 
region, is perigastric, or subdiaphragmatic abscess, a collection of pus 
walled in by the stomach, spleen, diaphragm, colon and the abdomi- 
nal walls. 

The most common cause is the irritation of a gastric ulcer which 
has nearly or quite perforated, and has formed adhesions with sur- 
rounding viscera. This was the cause in forty-one out of fifty-two 
cases analyzed by Fenwick, while in six it was associated with cancer 
and in four with abscess commencing externally. Pain in the epigas- 
trium or abdomen was the chief subject of complaint, and in most of 
the cases there was dyspepsia, sometimes vomiting. It is singular 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 747 

that hsematemesis was mentioned in only two cases. Fenwick thinks 
that in every case of perigastric abscess, except in persons affected 
with phthisis, cancer, or some other chronic exhausting malady, the 
first formation of the abscess will be accompanied by either collapse 
and signs of general peritonitis, or by sudden and severe pain in the 
epigastrium, attended with indications of local peritonitis. 

Fever is a prominent symptom, but physical signs are absent. A 
tumor, according to the same author, is rarely distinguishable except 
when the cause is cancer. It is dull, but afterward tympanitic on 
percussion, and not movable on inspiration or external pressure. The 
tension of the abdominal muscles prevents successful palpation. There 
may be arching outward of the ribs. The displacement of surround- 
ing viscera will depend upon the size of the abscess and the extent 
of adhesions. The diaphragm is pushed upward, and dulness may 
extend as high up as the angle of the scapula, in which case a pleural 
effusion is simulated. Breathing is embarrassed by the upward press- 
ure upon the lung and heart. Sometimes when gas is formed in connec- 
tion with the abscess, amphoric sounds on auscultation and percussion 
are heard both in the abdomen and over the thorax. To this condi- 
tion the name pyo-pneumothorax subphrenicus has been applied. The 
abdomen then becomes tense, tender, prominent, and tympanitic on 
percussion. (See p. 578.) It must be distinguished from left pneu- 
mothorax. Air in the pleural cavity pushes the left wing of the dia- 
phragm down, and hence increases the area of percussion-dulness and 
the palpability of the left lobe of the liver and spleen. In subdia- 
phragmatic abscess with gas, the liver and spleen are not palpable, 
nor can their area be limited by percussion. The heart is dislocated 
in pneumothorax, and its area tympanitic on percussion, while the im- 
pulse is seen in the epigastrium or to the right of the sternum. In 
subphrenic pneumothorax the heart is elevated, and the impulse seen 
in the nipple-line. At the same time there is tympany in the lower 
half of the cardiac area of dulness. Pyo-pneumothorax subphrenicus 
must not be mistaken for dilatation of the stomach. 

Palpation and Percussion of the Loins. Enlargements in 
these regions may be due to affections of the hidney (g. v.). They 
may, however, be due to enlargement or displacement of the spleen 
and liver (q. v.), or to tumors of the retroperitoneal glands. On the 
left side the possibility of perigastric abscess must be borne in mind, 
as sometimes the dulness and increased tension of the tumor extend 
as far down as the lumbar region. 

Palpation and Percussion about the Centre of the Abdo- 
men. Umbilical hernia, cancers of the stomach, liver, and intestine, 
sarcoma of the retroperitoneal glands, hydatid cysts of the liver, and 
tumors of the gall-bladder, together with floating hidney, spleen, and 
liver, all at times cause tumors which may be felt in this region. They 
must be distinguished from each other by methods already referred to 
under the organs named. The general principle upon which to proceed 
is to endeavor, by palpation and percussion, to discover the organ to 
which the tumor belongs. To this end careful inquiry should be made 
as to the time the tumor has been known to exist; its effect, if any, 



748 SPECIAL DIAGNOSIS. 

upon the general health ; its effect upon the function of the possible 
organs affected, and particularly as to the presence or absence of 
vomiting, constipation, diarrhoea, or jaundice. 

Tumor hi the region about the umbilicus may be from tubercular 
disease of the mesenteric glands (tabes mesenterica). It occurs nearly 
always in children, and presents the physical signs and symptoms of 
tubercular peritonitis, with the addition that enlarged mesenteric 
glands may sometimes be felt. Children grow pale and anaemic, 
waste away, have apparently causeless diarrhoea, the passages being 
foul and the food undigested. The abdomen is large, but appears 
larger when compared with the emaciated body. It is tender, its walls 
are thickened and less elastic than normal. Signs of tubercular dis- 
ease in other organs may be detected. 

Facts gathered in this way, carefully analyzed, and then studied 
with reference to the physical properties of the tumor (hard or soft, 
fluctuating, doughy, or not), will generally suffice for a probable diag- 
nosis. A positive diagnosis often cannot be made at the first examina- 
tion, and sometimes is possible only after watching the progress of the 
case for a considerable time. 

Enteroptosis. 

It is by inspection, palpation, percussion, and auscultation that we 
discover the anatomical cause for the symptom-group about to be de- 
scribed. Attention to this affection may only be called by the sub- 
jective symptoms. 

This disease or physical condition, called sometimes Glenard's dis- 
ease, after the physician who first called attention, in 1885, to its 
existence, has received, of late, much study. It is characterized by the 
falling down or descent of a number of the abdominal organs. This 
occurs on account of relaxation of the supporting ligaments, the num- 
ber of which Glenard puts at six. This relaxation is largely due to a 
flabbiness and hence lack of support of the abdominal wall ; or to 
strain from undue physical exertion ; or to the abuse of cathartics ; or 
possibly to injury. It is far more common in females who have borne 
children. It may be the result of feeble muscle-tone, following pro- 
longed illness. The degree of descent, and hence the severity of the 
symptoms, may vary from slight displacement of one or two organs to 
that of the large intestine, the stomach, the liver, the spleen, and the 
right kidney (sometimes both). In moderate cases but two of the liga- 
ments are relaxed — the ligamentum colico-hepaticum and the ligamen- 
tum gastro-colicum ; in the more severe all are affected. 

Symptoms. The objective symptoms are due to the slight displace- 
ment, and are either purely physical or arise from the alteration of the 
function of the stomach and the intestines. 

The subjective symptoms are due to the same cause. The displace- 
ment gives rise to local symptoms of weight, heaviness, and abdominal 
distress, amounting in some instances to pain, especially when in the 
upright position, and to protracted and pronounced neurasthenia. 
Later, we have the subjective symptoms of dyspepsia, gastritis, gastric 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 749 

dilatation, and intestinal atony, while the neurasthenic symptoms grow 
more aggravated. 

The earliest objective symptoms are : (1) Pulsation of the abdomi- 
nal aorta ; (2) a linear tumor or band about midway between the 
xiphoid cartilage and the umbilicus, extending transversely from four 
to six inches in length ; (3) gastroptosis, or descent of the stomach ; 
(4) movable right kidney. Later, the liver may fall from one to four 
inches, the spleen become palpable, and the left kidney movable. The 
transverse tumor above mentioned was held by Glenard to be the 
thickened transverse colon. Ewald, however, seems to have demon- 
strated that it is the pancreas. The displacement of the viscera is 
recognized by the methods previously detailed for physical examina- 
tion of the various organs. The patient must always be examined in 
the erect as well as in the recumbent position. Care must be taken to 
distinguish gastric dilatation from gastric descent. This can be done 
by careful percussion after inflation with air, by gastric diaphany, by 
measurement with a sound, and with fluids. Glenard laid much stress 
upon the splashing sound. This may or may not be present ; it may 
be of gastric or intestinal origin, usually the former. It does not 
depend upon the displacement as much as upon the occurrence of gas- 
tric dilatation. It occurs in other affections. 

An objective sign of diagnostic value, attention to which has been 
called by Treves, is the relief the patient experiences when the lower 
half of the abdomen is supported by a belt or by the hands of the 
patient or surgeon, when in the upright position. 

The objective signs of gastric origin depend upon functional or 
organic disease of that organ. We may have, on the one hand, only the 
perverted gastric secretion and digestion that go with gastric neuroses ; 
on the other hand, we may have the perverted gastric secretion of gas- 
tritis, gastric atrophy, or dilatation, and the evidences of diminished 
digestive, motor, and absorptive power of these affections. 

The subjective symptoms also depend upon the functional or organic 
changes in the stomach and intestines, upon the displacement of the 
organs, with or without the above, or upon the associate physical mus- 
cular condition of the individual and the state of the nervous system. 

Glenard divided the progress of the subjective symptoms into three 
periods : 

In the first there is gastric atony, when the patient experiences 
weight and burning after eating ; a short period of wakefulness about 
two o'clock a.m. ; a loose stool in the morning ; loss of strength. 

In the second period the patient cannot eat fats and starches, and the 
subjective symptoms arise late in the period of digestion. A dragging 
sensation or a feeling of emptiness occurs about three hours after meals. 
The patient awakens at two o'clock a.m., and remains awake for two 
or three hours. Constipation, at times alternating with diarrhoea, is 
present. There is continued loss of strength, and a tired feeling is 
complained of on rising. 

In the third period the symptoms of neurasthenia are most pro- 
nounced. The patient is emaciated, and complains of a constant weight 
and of cramps in the stomach. Constipation is obstinate, and the stools 



750 SPECIAL DIAGNOSIS. 

are scybalous and mucous. The patient is much prostrated and suffers 
from sleeplessness. The constipation and the intestinal distress are 
aggravated by aperients. Enemata must be resorted to, to relieve 
the symptoms. Intestinal catarrh or membranous enteritis is very 
likely to follow. 

Pain throughout the abdomen, especially when walking about or in 
the erect posture, is frequently complained of. Some authorities speak 
of tenderness on pressure over the solar plexus and of tender points 
along the vertebra. 

The disease is overlooked and the symptoms are attributed to neuras- 
thenia. It is often difficult to estimate which of the two preponderates. 

Diseases of the Peritoneum. Peritonitis. 

Inflammation of the peritoneum may be acute or chronic. It may 
be general or localized. Acute inflammation is rarely primary ; it 
may occur in the later stages of chronic Bright's disease, or other dys- 
crasia, as a terminal infection. If it follows exposure to cold, or 
trauma, it is called traumatic peritonitis. It is due in the large 
majority of cases to extension from organs which the peritoneum 
covers, or to perforation of one of the abdominal organs. In the first 
instance it may follow inflammation of any portion of the gastro- 
intestinal tract, of the pelvic viscera, and suppurative inflammation of 
the spleen and liver and of the pancreas. 

Peritonitis an Infection. In all instances the primary inflammation 
in the organs mentioned is due to some micro-organism, as the staphy- 
lococcus, the streptococcus, or the bacillus coli communis, and the 
peritoneal inflammation to subsequent extension of the infection. In 
peritonitis from perforation the element of infection is also the most 
important part in the process, as in ulcer of the stomach or bowels. In 
inflammation of the gall-bladder perforation may take place, with result- 
ing peritonitis. Abscess in the liver, spleen, or kidneys, bursting into 
the peritoneum, also leads to general peritonitis. The most common 
forms, however, are due to appendicitis or disease of the Fallopian 
tubes. Acute peritonitis may also occur in tuberculosis and in other 
systemic infections by direct infection. 

Symptoms. The onset of acute peritonitis depends in a measure 
upon the cause. When there is perforation the onset is sudden. 
Chilly feelings or a rigor occur, with intense pain in the abdomen. 
The pain is at first localized, but rapidly becomes general. It is con- 
stant, increases in exacerbations, and is very intense, aggravated by 
movements and by pressure. The patient lies on the back with the legs 
drawn up. The dorsal decubitus is assumed, in order that the tension 
of the abdominal muscles may be relieved. The location of the pain 
depends upon the seat of primary infection ; this is usually in the 
right or left lower quadrant, more marked about the tubes or the 
appendix. In perforation of an ulcer of the stomach the pain may 
be located in the back, or in the chest or shoulders. 

Physical Examination. On palpation the abdomen is extremely 
sensitive. The patient is unable to bear the weight of clothing or ex- 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 75 1 

ternal applications. The abdomen gradually becomes distended, and 
is tympanitic on percussion. The distention may become so great as 
to push up the diaphragm and interfere with the respirations, so that 
they are shallow, and may dislocate the heart, so that the apex-beat is 
seen in the fourth interspace. The splenic dulness may be obliterated 
entirely and the liver-dulness reduced. It is said that in some in- 
stances this may be obliterated, although recent observations show 
that such obliteration only occurs in the anterior portion of the abdo- 
men. Liver-dulness persists in the axillary region, though diminished 
in extent. This obliteration could only take place in perforative peri- 
tonitis. Osier points out that in pneumoperitoneum from perforation 
the anterior hepatic dulness may be obliterated, although dulness in 
the lateral region continues, on account of the effusion of fluid. If a 
patient with gas in the peritoneum is turned on the left side, a clear 
note is heard beneath the seventh and eighth ribs (hepatic region). 
The abdominal muscles are more or less rigidly contracted. Spasm of 
the muscle over the seat of primary inflammation takes place at once, 
and is a valuable indication of the origin of the infection. In some 
cases, usually when the inflammation is due to the streptococcus, there 
is not much distention of the abdomen, or it may be flattened entirely 
with board-like rigidity. In these instances pain is not so marked, and 
tenderness may not be complained of. 

The respirations are hurried and the superior thoracic type of breath- 
ing is seen, because the action of the diaphragm is painful. The act of 
speaking or coughing increases the pain, and the patients are unable 
to take a full breath without suffering. With the occurrence of pain 
and local signs vomiting usually sets in. It is painful and at first 
is complete, the contents of the stomach being ejected and then a yel- 
lowish bile-stained fluid ; later, the vomit becomes greenish in color. 
Complete vomiting is replaced by simple regurgitation of fluid, so that 
on the slightest motion of the patient, or on taking a small amount of 
fluid, the characteristic greenish-colored fluid is regurgitated without 
action of the diaphragm. This may be almost continuous for from 
twenty-four to forty-eight hours. The tongue is at first furred, but 
later becomes dry, and often is cracked and red. The bowels are con- 
stipated. They may be loose at first, but constipation is characteristic. 
The intestines are paralyzed from overdistention and from oedema of 
the walls due to inflammation. 

The general symptoms are marked. After the chill the temperature 
rises to 104° or 105°. In septic cases it continues at this point, or 
may rise to a greater height. If cases progress rapidly, a temperature 
of 105° or 106° on the second or third day is not uncommon. In 
other cases after the initial rise the subsequent elevation is not so great, 
but there is not much difference between morning and evening temper- 
ature unless there is an abscess. 

The urine is scanty ; micturition may be frequent and painful, par- 
ticularly if the inflammation began in the pelvic organs. The urine 
usually contains a large amount of indican in the suppurative form. 

The appearance of the patient at the height of the disease is charac- 
teristic. The expression is anxious, the face is pinched, the eyes 



752 SPECIAL DIAGNOSIS. 

sunken. Vomiting causes wasting. The collapse is marked, with 
the characteristic facies previously described. (See Expression.) The 
pulse is rapid and feeble and soon becomes thready, ranging from 110 
to 150. In the first stages it may be small and hard. Attention has 
been called frequently to the peculiar wiry pulse of the early stage of 
peritonitis. 

In severe cases death may take place in from thirty-six to forty-eight 
hours. Usually a fatal termination does not take place for five or six 
days, and may be delayed longer. The vomiting persists, collapse 
with falling temperature ensues, the pulse becomes rapid and thready. 
Throughout the entire attack, unless symptoms of septicaemia are 
marked, the mind is clear. The patient dies of paralysis of the heart. 
Septicemic symptoms are indicated by a dusky color of the face, rapid 
and irregular pulse, slight delirium, dry, brown tongue, and other evi- 
dences of the typhoid state. 

If the cases are prolonged, some effusion may take place into the 
peritoneal cavity. Dulness is noted in the flank, and if it is possible 
to move the patient, it alters with the position. If recovery takes 
place, particularly in tuberculous cases, the affection may become cir- 
cumscribed and be indicated by dulness, which is not movable. 

Diagnosis. It is essential in making a diagnosis to ascertain, if 
possible, the primary source of the infection or inflammation. To 
determine this we inquire the age, sex, and history of previous disease 
of the patient. In young male adults appendicitis is first to be thought 
of ; in females inflammation of the pelvic organs. In chlorotic sub- 
jects, if the pain is high up, a history of ulcer of the stomach must be 
inquired for. Later in life, particularly if there has been jaundice, 
the possible history of frequent attacks of gallstones and of hepatic 
disturbances must be ascertained. All forms of intestinal obstruction 
must be sought for. Frequently, however, a definite cause cannot be 
ascertained. If it occurs in the course of typhoid fever, it is usually 
due to perforation, but the occurrence of pain may not be complained 
of, on account of the mental state of the patient. Under other circum- 
stances the symptoms cannot be overlooked. 

Acute peritonitis must be distinguished from entero-colitis. The 
distinction is not usually difficult if attention is paid to the develop- 
ment of the case. The pain is not so severe in entero-colitis ; it is 
more colicky in character. The general tenderness is not so great as 
in peritonitis, and the distention does not interfere with respiration to 
such a marked degree. Diarrhoea is more common in entero-colitis ; 
collapse, if present, is not so pronounced. 

Acute hemorrhagic pancreatitis may simulate peritonitis in the sudden 
intensity of pain and the occurrence of shock. 

The diagnosis from obstruction of the bowel is difficult in the absence 
of a distinct history, but in peritonitis we do not have stercoraceous 
vomiting until late. The tympanites and the pain are more general. 
Peritonitis frequently accompanies or is due to obstruction. A 
tumor, if present, may point to the true nature of the case, and, if 
there is any discharge from the rectum, invagination may be the ex- 
citing cause. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 753 

Peritonitis is simulated by a condition to which the name hysterical 
peritonitis has been applied. It occurs in hysterical subjects, and 
every feature of the true form is imitated. The mode of onset, the 
decubitus, the difficulty in micturition, and the local distention and 
tenderness of the abdomen are characteristic of both. In a few cases 
which we have seen the vomiting is not of the nature of true periton- 
itis, either in the mode of ejection or the character of the fluid. It 
must not be forgotten that even the temperature may be elevated and 
collapse take place in the hysterical form. In the cases which I have 
seen the abdominal facies does not develop, while, on the other hand, 
the facies of hysteria, with the self-interest which the patient exhibits, 
and the precision with which symptoms are narrated, coupled with 
emotional or other manifestations of hysteria, point to the true nature 
of the affection. Other symptoms of hysteria may arise. The case is 
judged by the history of these associated manifestations and the per- 
manent stigmata of the disease. There is always a positive absence of 
cause and of disease in any of the abdominal viscera. Sometimes, in 
these cases, if the attention of the patient is diverted, the tenderness 
on pressure may not be complained of. I am not familiar with the 
results of examination of the urine in this form of peritonitis. Indi- 
can should not necessarily be increased, as we find it to be in acute 
suppurative peritonitis. 

Rheumatism of the Abdominal Walls. There is absence of a history 
of sudden acute pain followed by general pain. The fever is not so 
great. The respirations are not interfered with, the pulse is not so 
rapid, and symptoms of collapse do not supervene. A rheumatic 
pharyngitis or inflammation of muscles in some other portion of the 
body may occur simultaneously. 

Local Circumscribed Peritonitis. The causes of localized 
peritonitis are those of general peritonitis — that is, extension of inflam- 
mation from neighboring viscera, or perforation of the viscera. In the 
latter instance the inflammation does not become general, if rapid local 
inflammation shuts off the perforated area from the general cavity of 
the peritoneum. Local peritonitis of mild degree, and local or cir- 
cumscribed peritonitis with suppuration, are therefore found in the 
regions previously indicated, from which a general peritonitis may 
develop. The inflammation, however, if retained by a limiting wall, 
may, after suppuration has taken place, gradually extend and the pus 
burrow in various directions. In such cases of localized peritonitis as 
may exist in the upper half of the abdomen, a sub-diapJwagmatic 
abscess may form, or an abscess containing air and pus, known as pyo- 
pneumothorax subphrenicus. If the inflammation is secondary to 
disease of the pancreas, it may be limited to the lesser peritoneum and 
cause the physical signs of effusion in this cavity. (See Disease of 
the Pancreas.) Sub-diaphragmatic abscess is not limited to the lesser 
peritoneum. It can only be recognized by the history of the previous 
disease, which may cause perforation, and by the general symptoms of 
abscess. If the abscess is on the left side, there is an extension of 
dulness upward toward the scapula, the lower limit of the lungs in 
health ceasing at the eighth or ninth interspace. There may also be 

48 



754 SPECIAL DIAGNOSIS. 

dulness in the axillary region. If the abscess is on the right side, it 
may simulate enlargement of the liver, and be characterized by marked 
increase in dulness anteriorly, laterally, or posteriorly. Localized peri- 
tonitis in the lower half of the abdomen is due to disease of the vermi- 
form appendix, or to disease of the Fallopian tubes. The localized 
signs are, first, those of pain and tenderness ; second, the development 
of tumor. 

Chronic Peritonitis. The symptoms of diffuse peritonitis, chronic 
in course, may follow the acute, or may occur in the course of tuber- 
culosis. The intestines and peritoneum are matted together. General 
pain and tenderness, Avith a prolonged period of ill health, attend the 
diffuse form. (See Tuberculous Peritonitis.) In the chronic forms, 
if there is considerable fibrous proliferation, even though not can- 
cerous or tuberculous, the abdomen becomes retracted, the muscles 
rigid, the note over the abdomen modified or dull tympanitic. The 
modification may be detected in the upper half of the abdomen par- 
ticularly, and especially over the liver. Sometimes a fremitus can be 
felt. The patients are under weight and without strength. The pain 
may continue a long time. It finally results, at least clinically, in 
such compensation that the patient is able to continue his usual occu- 
pation. Localized bands form, and may cause local sensations of a 
dragging character, or pain with drawing or pulling sensations ; but, 
save the local symptoms, these are not serious, unless it should happen, 
as has been seen in intestinal obstruction, that coils of intestine are 
twisted about the bands or caught in them, thus leading to obstruction. 

Cancer of the Peritoneum. 

It usually occurs in the aged, and follows cancer in other organs, 
as the stomach, liver, or uterus. Occasionally it is primary. The 
omentum is indurated, and forms a mass which lies transversely across 
the abdomen in the upper zone. Ascites usually develops, and the 
exudation is bloody. The disease occurs more frequently in women 
than in men. With the development of ascites there is emaciation. 
The surface of the indurated omentum is irregular. It may be pain- 
ful on pressure. A tumor of the same physical character is seen in 
tuberculous peritonitis, and I have seen several such tumors in the 
aged without apparent cause, unless from proliferative peritonitis. (See 
Tumor.) Progressive emaciation, chronic ascites without cause, and 
a localized tumor without the occurrence of fever point to the proba- 
ble nature of the case. Sometimes pain is the most pronounced symp- 
tom. If these symptoms are present with signs of cancer in some 
other organs, as the stomach, rectum, or uterus, there is probably 
primary cancer of the peritoneum. 

Retroperitoneal sarcoma, or Lobstein's cancer, is central or lateral, 
deep-seated, and usually fixed. It is accompanied by the general symp- 
toms of cancer and by ascites. The growth is very large. It can be 
detected above the sacrum by rectal examination. The intestines are 
in front of the growth, causing an unusual sensation to the hand, as in 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 755 

Burrow's case, like a hydatid fremitus. Lockwood's cases were 
believed to be solid ovarian tumors. 

Sarcoma of the glands and the tissues in the above mentioned space 
is, according to J. Dutton Steele, slightly more common in males than 
in females ; more common in the first decade or after the fiftieth year. 
Its duration is about nine months. Of the sixty-five cases collected by 
Steele 39 per cent, were spindle-celled sarcoma, 34 per cent, round- 
celled sarcoma, 14 per cent, lympho-sarcoma, and 13 per cent, were 
mixed cases. The growth originates in the lymph glands or in fibrous 
connective tissue about the kidney, the spinal column, the pelvis, or 
the sheaths of the bloodvessels. The onset is insidious. The first 
symptoms are the presence of a tumor, or the effects of pressure upon 
the vessels, nerves, or viscera of the abdominal cavity ; they depend 
upon the site of the tumor. Varicocele is of frequent occurrence. It 
is often impossible to distinguish it from malignant disease of the kid- 
ney or of the suprarenal bodies. The diagnostic features are (a) the 
rapid growth ; (b) the position of the colon, which is pushed in front 
of it, particularly if the tumor is lateral ; (c) the pressure symptoms ; 
(d) the tumor may move with respiration or independently, and may 
fluctuate. 

Tuberculosis of the Peritoneum. 

The tuberculous process in the peritoneum may be either acute or 
chronic. In rare instances it may continue without any symptoms, 
either local or general. 

Aeute tuberculous peritonitis may exactly simulate suppurative peri- 
tonitis, although usually the course is more prolonged and the fluctua- 
tions of temperature less pronounced. In other respects, it cannot be 
distinguished from acute general peritonitis, save by the absence of 
the causes of the latter. A history of exposure to tuberculous infec- 
tion, or the presence of tuberculosis in some other portion of the body, 
may be of service in determining the nature of the case. Often there 
occurs in a short time associate tuberculosis of other serous membranes, 
so that tuberculous pleurisy or tuberculous pericarditis will supervene, 
an associate process which does not take place in ordinary peritonitis. 
There is diarrhoea in most cases — at least it has been present in the 
few instances ivhich I have seen of this form of tuberculosis. Never- 
theless, the diagnosis is sometimes impossible. Henry has called 
renewed attention to the occurrence of inflammation about the navel as 
a sign of tuberculous peritonitis. He believes the periumbilical ery- 
thema is pathognomonic of the affection. 

Acute tuberculosis of the peritoneum may precisely simulate appen- 
dicitis in, first, the local symptoms and signs ; and, second, the subse- 
quent infection of the peritoneum. In acute tuberculous appendicitis, 
however, the signs of a tumor are not so marked as in true appendi- 
citis. Nevertheless, in one instance, Keen operated upon a patient of 
mine, a healthy laborer in a rolling-mill, who had the classical symp- 
toms of appendicitis. At the operation the appendix was found to be 
perforated and hanging in a local abscess. A fecal, fistula ensued 
which did not heal, and within two months the patient died of general 



756 



SPECIAL DIAGNOSIS. 



tuberculosis. The appendix was the seat of primary tuberculous 
ulceration. In a second instance the appendicitis arose in the course 
of tuberculosis. 

In a third instance the patient, aged forty-five years, was admitted 
to my wards in the Philadelphia Hospital, with high fever and pain 
in the abdomen, at first more marked along the margin of the 
liver. By the end of twenty-four hours it became more decided in 
the right lower quadrant of the abdomen ; tenderness at McBurney's 
point was distinct ; the area was enlarged and dull on percussion, the sur- 
face slightly oedematous. Fluctuation could not be detected. Exten- 
sion of the leg was painful. Rapid general peritonitis ensued, during 
which the surgeon saw him, but declined to operate until the subsi- 
dence of the attack. When the attack subsided the local signs of 
tumor were not present. The fever persisted irregularly for a short 
time, while the more acute peritoneal symptoms subsided ; then the 
right pleura became infected, and cough ensued with expectoration of 
mucopurulent fluid. It did not contain tubercle bacilli, however. 
Subsequently the left pleura and the pericardium became involved. 
During the entire course of the disease there were diarrhoea, most pro- 
nounced sweats, rapid emaciation, and exhaustion. Death took place 
at the end of five weeks, and at the autopsy general serous tubercu- 
losis was found. 



Fig. 193. 



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95 ■*■ ■*- 1 1— 



Tuberculous peritonitis. Subnormal temperature. 



While in a number of instances the symptoms are acute and alarm- 
ing, in the larger proportion of cases the process is more chronic, and 
is attended by characteristic local and general symptoms. In the pro- 
longed and moderate cases there may be continued fever of moderate 
degree, or it may be remitting in type. In old people the temperature 
is frequently subnormal. (See Fig. 193.) There is more or less 
rapid emaciation. The sweating is profuse and characteristic. The 
fever is high but irregular in type, in more severe cases approaching 
the remittent form. The general symptoms resemble typhoid fever. 
Indeed, symptoms of the typhoid state may ensue. 



PLATE XXXVII. 




Tuberculosis of the Peritoneum. 

Abdominal exudate (not freely movable); omental tumor. Consoli- 

dation at apices. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 757 

The Local Symptoms. Four classes are seen : (1) Abdominal en- 
largement with effusion ; (2) enlargement with tumors ; (3) a combina- 
tion of the two ; (4) enlargement without evidence of fluid or tumor 
in the abdomen. In the latter form and in the forms in which tumors 
are present the abdomen subsequently may undergo retraction. 

1. Enlargement with Effusion. The local symptoms and physical 
signs are those of ascites. The abdomen is never as distended, however, 
as in the ascites of cirrhosis of the liver. Often the fluid is confined 
by adhesions which may distinctly localize it in the right or left quad- 
rant of the abdomen, in which situation fulness and fluctuation may 
be readily detected. 

2. Tuberculosis with Tumors. (Plate XXXVII.) The tumors are 
usually in the upper zone of the abdomen, and may be localized in either 
quadrant, or extend from the right to the left. They are usually due 

Fig. 194. 




Tuberculous peritonitis ; pulmonary tuberculosis. + The site of cardiac impulse. 



to tuberculosis of the omentum, with secondary contraction. In some 
instances a hard, indurated tumor, somewhat tender on pressure, may 
extend across the abdomen midway between the xiphoid cartilage and 
the umbilicus. It may be as low as the umbilicus, and vary from two 
to four inches in width. It may be continuous with the liver-dulness. 
In other instances more distinctly localized masses may be felt. These 
may be to the right or to the left of the umbilicus. In other instances 
they are hard, slightly tender, with an irregular surface. They may 
be movable and vary with the position of the patient. I have 



758 SPECIAL DIAGNOSIS. 

never seen tuberculous masses in the lower quadrants. In chil- 
dren with tabes mesenterica they may be made out close to the verte- 
bral column in the median line, extending to the brim of the pelvis, 
although at the lower portion they are not so distinct. The dulness 
over the tumors is varying, depending upon the relation to the bowels 
and the degree of intestinal distention. Instead of dulness a modified 
tympany may be observed, or muffled resonance. 

3. Cases in which Effusion and Tumors are Present at the Same Time. 
These present symptoms common to the two conditions, although the 
tumors are not so distinctly defined. 

4. Absence of Effusion and Tumors. When effusion and tumors 
are not present the thickened peritoneum and more dense intestinal 
walls lead to a modified dulness over the entire abdomen. When re- 
traction takes place the resonance is of a woodeny character, the abdo- 
men is more or less tender, and ill-defined indurations may be present. 
The term carreau is applied to this induration. 

In not a few instances the local physical signs may apparently be due 
to inflammation of the liver, on account of extensive perihepatitis. In 
the case of a child under my care the local signs during life were of 
this character, and the symptoms were simply those of loss of appetite, 
with discomfort, weight, and fulness below the sternum. Both the right 
and left lobes of the liver were covered with an enormous thickening 
due to tuberculous inflammation. Simple plastic peritonitis occupied 
the lower zone. 

Apart from the general symptoms and the local physical signs the 
other symptoms are not distinct save those due to tuberculosis in other 
situations. The appetite is usually poor, there is some atonic dyspep- 
sia, vomiting may occur at regular intervals ; the bowels may be con- 
stipated, although in my experience they have usually been relaxed. 
The patient becomes anaemic, the skin harsh and dry. Emaciation 
may progress to an extreme degree. Eruptions and boils may break 
out, some oedema of the ankles may occur. Death takes place from 
exhaustion and from the development of tuberculosis in other localities. 

The diagnosis is difficult. Cases belonging to the first and fourth 
classes above mentioned probably present the greatest difficulties. 
The age modifies the difficulty of diagnosis. Peritoneal tumors, with 
or without effusion in young subjects, are almost always due to 
tuberculosis. In the aged they must be distinguished from carci- 
noma or chronic peritonitis from other causes. The association of 
diarrhoea with the symptoms is rather against carcinoma. Sacculated 
effusions may be confounded with abdominal tumors, as of the ovary. 
The resemblance is more pronounced if the tubercles develop primarily 
in the tubes or uterus. In a recent case the autopsy disclosed a large 
caseating ulcer inside of the uterus, and tuberculosis of the Fallopian 
tubes and peritoneum. The right tube was chiefly affected. The 
effusion during life was sacculated in the right lower quadrant, was not 
movable with the patient, and fluctuated both on external palpation 
and with bimanual palpation per vaginam. It was impossible to dis 
tinguish it except that there was dulness instead of resonance in the 
flanks. As Osier has pointed out, the association with salpingitis 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 759 

must arouse suspicion, particularly if at the same time disease is found 
in some other organ of the body, as the apex of the lungs or the 
pleura. In males the primary lesion is often in the testicles. The 
history of the case and the development of the disease in an irregular 
manner, associated with gastro-intestinal disturbance rather than dis- 
turbance of uterine function, are points in favor of tuberculosis. Tym- 
panites is of frequent occurrence. 

Diseases of the Stomach. 

The stomach is a canal in which the food is detained for the purpose 
of solution. Its walls are made up of mucous membrane, muscle, and 
peritoneum. It is richly supplied with bloodvessels. Because of its 
great functional activity it has an abundant nerve-supply. It is, more- 
over, surrounded by rich plexuses of sympathetic nerves, through which 
and its special nerve, the pneumogastric, it is in intimate relation with 
every organ of the body. 

The Symptomatology . The local symptoms of disease of the stomach 
are dependent upon : (1) The morbid process which affects it ; (2) the 
effect of the process upon the anatomical structure of the organ (atro- 
phy, dilatation, tumor), whereby the size is affected ; (3) the effect 
upon its function. 

1. The Morbid Process. The symptoms due to the morbid process are 
not different from the symptoms of similar morbid processes elsewhere, 
save that they are modified by the function of the organ or its special 
construction as a canal. Hence, congestions are attended by discharge 
of mucus ; inflammations are attended by pain and by a flow of mucus 
and pus ; ulcers by pain and the accidents of ulceration (hemorrhage) ; 
malignant disease by pain and swelling (tumor), and its accidents, hemor- 
rhage and obstruction ; while to each belong the general phenomena 
which attend it. But the stomach is highly sensitive and resents the 
intrusion of disease or of that which (1) causes disease or (2) irritates 
the affected part. Expression of this resentment is shown in hyper- 
sesthetic symptoms (see the Neuroses), as pain; in the abolition or 
derangement of function ; and in the great pathological reflex act of 
the stomach — vomiting. It will be seen later that this may be a symp- 
tom of every local morbid process of the organ, either directly because 
of the disease or of its exciting cause, both of which are operative in 
irritant inflammations ; or indirectly because the process has set up 
undue sensitiveness. In the latter instance any material, as food, which 
the stomach is accustomed to receive, becomes as much an irritant as 
mucus, pus, or blood. 

2. Anatomical Symptoms. The morbid processes modify the ana- 
tomical structure and lead to other morbid conditions, as we see when 
dilatation succeeds inflammation or obstruction of the orifices. The 
symptoms of the secondary conditions are the same as elsewhere — in 
atrophy, diminution in size ; in dilatation, increase in size, with retention 
and fermentation, and finally discharge of the contents by vomiting. 

Nerve Mechanism. In the consideration of the symptomatology of 
gastric diseases the anatomical relation, by its vascular and nervous 



760 SPECIAL DIAGNOSIS. 

connection, must be considered. The student is sufficiently familiar 
with physiology and pathology to know that each organ has a represen- 
tative in the central nerve-mass, the brain, and that disease in one 
organ will influence the function and create morbid symptoms in 
another which is related to it through intimate nervous connections. 

The central representative or centre is influential in proportion to 
the power and activity of its peripheral adjunct. It is, moreover, in- 
fluenced by higher centres, the psychical, and it in turn modifies them. 
It influences or modifies lower centres, (1) functional, (2) vasomotor, 
(3) motor, or (4) sensory. The result of this mechanism is : 1. That 
functional alteration or organic disease of (a) the gastric centre, or (6) 
of centres of higher control, or (c) of the nerve that connects the centre 
and the organ — pneumogastric nerve— produces gastric symptoms. 2. 
That gastric diseases produce symptoms in other organs, as cardiac 
palpitation (reflex). 3. That disease of other organs produces gastric 
symptoms or disease, as the vomiting of pregnancy, or of renal calculus, 
or of disease of the testicle, or the gastritis of nephritis. Thus vomiting 
is caused by emotion (high centre), influencing the pneumogastric (lower 
centre) ; by a tumor pressing or destroying the pneumogastric centre ; 
or by a tumor, as aneurism, pressing on the pneumogastric nerve. 
I have taken the simplest illustration. When we come to the study 
of gastric neuroses the extraordinary influences of the nervous mechan- 
ism will be appreciated ; or, when hysteria is studied, the physiology 
of its extreme gastric symptoms will be recognized. When the mech- 
anism and clinical course of vomiting are studied it will be found 
among other causes to be frequently due to affections of the blood, the 
poisons of which irritate cerebral centres or nerve plexuses in the 
stomach. 

Vascular Mechanism. But gastric diseases also arise because of the 
vascular supply. Thus in heart disease with venous stasis the gastric 
veins become the seat of congestion, with consequent gastric catarrh ; 
or hepatic disease will cause portal congestion and gastric catarrh. 

3. Functional Symptoms. Any local disease of the stomach must 
influence its function ; therefore, conversely, functional symptoms 
must be present in all local diseases. But functional disorder may be 
present without local anatomical change ; the impairment is nearly 
always induced through the influences of the nervous system. The 
functions of the stomach are to digest and to absorb the products of 
digestion. The former function is motor and chemical, the complete- 
ness of which depends upon mixture of the food with, and solution in, 
the gastric juice. The symptoms, therefore, must be due to changes 
(1) in the motor, (2) in the secretory, and (3) in the absorptive func- 
tions of the organ. The functions may be increased or diminished ; 
the former are the primary and usually temporary aberrations ; the 
latter succeed the former, and are permanent. The functional symp- 
toms, therefore, are the symptoms of what we know as indigestion or 
dyspepsia. They are described in the account of the subjective symp- 
toms and also in the section on Gastric Neuroses. 

Toxic Symptoms. The toxic symptoms arising in gastric disease are 
worthy of a few words. They are nervous symptoms due to the 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 761 

absorption of ptomaines or imperfect products of assimilation. If 
absorption of the toxines takes place suddenly and in large amounts, 
coma and convulsions occur (Kussmaul's symptom) ; or, if gradually, 
hypochondriasis, melancholia, mental depression, with vasomotor phe- 
nomena of various kinds, arise. 

It is observed, therefore, in unravelling the symptomatology of gastric 
disease, that we must first note : (A) The subjective symptoms due 
(1) to morbid processes, (2) to alterations of function, (3) to alterations 
of size (sense of fulness, etc.). (B) The objective symptoms due (1) 
to morbid processes, (2) to alterations of function, (3) to alterations of 
size. 

Diagnosis from Disease of Contiguous Organs Functionally Related. 
The student will soon learn that diseases of the stomach which are 
functional in character cannot be differentiated with ease from diseases 
in other organs functionally related. He will find that to draw hard- 
and-fast lines between gastric and intestinal indigestion, or between 
so-called disordered gastric and hepatic function, is generally impos- 
sible. Organs which are closely related in physiological function, and 
which have nerve-supply and blood-supply in common, cannot be dif- 
ferentiated when disordered function is considered. Hence, indigestion 
and biliousness, or simple acute gastritis and duodenitis, are beyond 
the pale of close discrimination. In fact, the symptoms of each blend 
in a manner. 

In addition to the examination of the stomach, in order to judge cor- 
rectly of the nature of gastric lesions, as may be inferred from what 
has been written above, we must ascertain (1) whether the gastric symp- 
toms are dependent upon disease of other organs — particularly the eye, 
nose, and genitalia, the heart and kidneys — by an examination of each 
organ ; and (2) whether other symptoms are created by gastric disease. 

The Stomach in Other Diseases. Diseases of the stomach may 
frequently mask other diseases ; in other words, patients will complain 
of gastric symptoms which are but concomitant phenomena, behind 
which there are graver conditions. Thus, in disease of the kidney, in 
phthisis, in chronic bronchitis, in emphysema, in valvular disease of 
the heart, catarrh of the mucous membrane of the stomach is of fre- 
quent occurrence, depending upon the primary disease. 

In tuberculosis the local gastric symptoms often are the more promi- 
nent features. Thus in the earlier stages of phthisis loss of appetite 
and vomiting are of constant occurrence. The dyspeptic symptoms 
in a large number of cases precede the pulmonary symptoms, and may 
be so pronounced as to mask them entirely. The patients are usually 
delicate and anaemic ; they complain of loss of appetite and mild indi- 
gestion ; there is some regurgitation of food ; they are feeble and 
languid. They are treated for chronic catarrhal gastritis, but do not 
improve. On examination of the lungs the physician is surprised to 
find a small area of consolidation, and upon inquiry will find subjec- 
tive symptoms of tuberculosis to have been present for a considerable 
time. Every practitioner is familiar with the scores of patients with 
phthisis, even when the disease is far advanced, who believe that their 
symptoms are entirely due to disorder of the stomach. In addition 



762 SPECIAL DIAGNOSIS. 

to the early catarrh that precedes tuberculosis, other gastric symptoms 
may occur. The well-known association of simple ulcer and phthisis 
is familiar. Both occur at the same time of life, yet the gastric symp- 
toms may prevent investigation into those of pulmonary origin. In 
ancemia and chlorosis changes in the digestive tract are common. On 
account of the general blood-condition the functions of the stomach 
are impaired. Here, too, we frequently have the association of nicer 
with the general condition. Danger of overlooking either is not so 
great as in tuberculosis. 

In valvular affections of the heart, chronic catarrh of the stomach 
may result from venous congestion. The symptoms may point to the 
gastric condition alone. In all cases of chronic gastric catarrh it is 
necessary to examine carefully into the condition of the heart. Over 
and over again patients apply for treatment not on account of cardiac 
symptoms, but because of gastric disorder. They will be treated in 
vain unless the primary cardiac affection is ascertained. Many cases of 
gastric catarrh have been cured by the use of digitalis. In disease of 
the kidneys the stomach is frequently involved. Vomiting and other 
symptoms of gastric disorder may occur long before dropsy or any 
objective sign which would lead to a correct diagnosis. The gastric 
symptoms are due to chronic uraemia. In other conditions of the 
genito-urinary tract gastric symptoms also occur. This is particularly 
noticeable in long-standing retention from chronic obstruction. Renal 
tumors may cause only disturbances of digestion, while gastric symptoms 
due to movable kidney are well known. The symptoms in the latter con- 
dition arise, first, from mechanical causes, as the pressure of the kidney 
on the pylorus, and, secondly, from the influence on the nervous system. 

Disease of the Liver. The intimate relationship of the liver and 
the stomach is such that when one is the seat of serious functional dis- 
turbance the other is likely to be affected. Frequently it is impossi- 
ble to draw fast lines as to which organ is the primary seat of disorder. 
The abuse of alcohol frequently induces chronic gastritis, and also 
causes cirrhosis of the liver. On the other hand, cirrhosis of the liver 
is frequently the cause of chronic gastritis secondary to the portal 
congestion. 

Diseases of the Nervous System. The relationship of disease of the 
central nervous system to disturbance of the gastric functions has 
frequently been adverted to. (See Vomiting.) In sclerosis of the 
posterior columns of the cord this is more striking than in any other 
spinal disease. Not only do we have gastralgia and gastric crises, but 
moderate symptoms of indigestion, with hyperesthesia and slight gas- 
tralgia, may be the first symptoms of locomotor ataxia. 

Diabetes. Diabetes may continue (in its course) for a long period 
of time, during which the patient is thought to have stomach-trouble, 
before an examination of the urine reveals the true nature of the case. 

Opinions differ as to the relationship of gout and rheumatism to 
gastric disorder. Some writers believe that a specific gouty inflammation 
of the stomach, due to the uric-acid diathesis, is of frequent occurrence, 
and that one of the prominent manifestations of gout is dyspepsia in 
all its forms. The French consider gastric disturbances to be frequent 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 763 

expressions of the rheumatic diathesis. The relationship of the two, 
however, is thus far not fully developed, although, in these conditions, 
it is not usual to overlook the presence of either of the diatheses when 
symptoms of gastric disturbance occur. It is essential to bear in mind 
that in persons of a rheumatic or gouty diathesis gastric disturbances 
are more likely to occur than in healthy individuals ; their successful 
management depends upon the recognition of the fundamental diathesis. 
It is more than probable that gastric disorders, along with defective 
metabolism, is primary in both affections. 

The Data Obtained by Inquiry. 

The Social History. In no other group of diseases than in 
those about to be considered, unless those of the nervous system, is it 
more important to inquire into the social history. This is true, because 
most of the so-called gastric disorders have their foundation in neuras- 
thenic states, the probability of which, of course, must be carefully 
sifted from the many possibilities. Age. Early age predisposes notably 
to gastro-intestinal disorder. In later life the catarrhs which arise 
from improper exposure or indiscretions in eating or occupation are 
common. The menopause is often associated with gastric disorders. 
The sex is not of great diagnostic significance, except from its relation- 
ship to the excesses in eating and drinking of one class. Those occupa- 
tions which prevent out-door exercise, or which compel exposure to 
toxic substances, or require stooping or constrained positions, or over- 
tax the eyes, invite gastric diseases. Habits of eating and drinking, 
both as to time and mode of eating, and the character of food and 
drink, must be brought out in the inquiry. The use of tobacco and 
other stimulants and narcotics must be noted. The hours devoted to 
vacation and work are to be learned, as fatigue bears a great part 
in gastric disease. 

The Family History. Heredity plays but a small part except 
in gastric carcinoma and in gastric neurasthenia. 

The History of Previous Disease. The occurrence of infec- 
tious diseases antecedent to the gastric disorder must be inquired about, 
for, either because of the attendant gastritis or of the resulting defec- 
tive innervation, they predispose to gastric disease. The excessive 
feeding in the convalescence of typhoid fever, it seems to the writer, 
is frequently the cause of gastric dilatation. Any prolonged illness 
which weakens the muscular system and lowers the tone of the nervous 
system will be likely to cause gastric disease. 

It will be learned elsewhere that gastric affections occur secondary 
to many local diseases, as of the heart, the lungs, and the kidneys. 
Inquiry as well as an objective investigation must be made, to deter- 
mine the presence of possible primary diseases. Disorders which inter- 
fere with the mechanical support to the intra-abdominal organs must 
be inquired for. Pregnancy, antecedent ascites, or a large tumor may 
so weaken the abdominal muscles as to lead to gastro-enteroptosis. 
Finally, a history of the ingestion of corrosive poisons must be sought 
for in cases of gastritis. 



764 SPECIAL DIAGNOSIS. 

It is very important to learn whether the patient has been subjected 
to the various causes of neurasthenia, which, with the history of the 
occurrence of neuropathic symptoms, make valuable data, pointing to 
the nature of many gastric neuroses. 

The Subjective Symptoms. The following subjective symptoms 
may be complained of : Disorder of appetite, bad taste in the mouth, 
thirst, eructations, pyrosis, distress or weight after meals, burning after 
meals, flatulency, nausea, vomiting, constipation, diarrhoea, pain, vertigo, 
and cardiac palpitation. Nearly all the subjective symptoms are gastric 
neuroses, and will be detailed in the chapter devoted to the neuroses. 

Bad Taste. It is usually due to acute catarrh. It may be present 
in chronic catarrh. It is said to be characteristic of the acute form of 
gastritis popularly known as biliousness. 

Thirst. Thirst is not a symptom of gastric disorder alone ; it is a 
symptom of diabetes and all conditions in which the body has lost 
fluids, as water by sweating, vomiting, or purging, or by evaporation 
and combustion (fever) ; or blood by hemorrhage. It is common in 
acute and chronic gastritis, particularly in the alcoholic form. 

Distress, Weight, and Burning. They are frequent complaints, 
and may come on immediately after meals. They may be due to dys- 
pepsia, hyperacidity, dilatation, bacterial fermentation, and flatulency. 
They exist in varying degrees, either singly or combined. (See Gas- 
tric Hyperesthesia.) 

Nausea. This symptom is usually associated with vomiting. In 
some persons it is impossible to excite vomiting, although they may 
suffer intolerably from nausea. Nausea is akin to vomiting in its 
mechanism and clinical associations (g. v.). It is a common incident 
in chronic interstitial nephritis. In old people, with arterial sclerosis 
and defective renal elimination, it is common. It may be due to irri- 
tating ingesta, to hyperacidity, to gastrectasia, or to toxins formed 
within the stomach. 

Vomiting. Vomiting takes place when the stomach is compressed 
by the abdominal muscles and diaphragm, coinciclently with relaxation 
of the so-called cardiac sphincter of the oesophagus. Sometimes there 
are nausea and violent efforts at expulsion on the part of the stomach, 
but no vomiting occurs, because the cardiac orifice of the stomach is 
not opened at the same time. Again, there may be profound relaxa- 
tion of the oesophagus, but no compression of the stomach by the dia- 
phragm and abdominal muscles. Both factors must operate at the 
same time to result in vomiting. This explains why it is that some 
persons suffer extreme nausea and have even violent retching, but are 
unable to vomit. 

It is to modern physiologists — Schiff and Budge and Brunton — that 
we owe a correct explanation of the physiology of vomiting. 

From them we learn that there is a nervous centre for vomiting, 
which is seated in the medulla oblongata, in close proximity to and 
intimately connected with the respiratory centre. It is to this centre 
that impressions are sent from the brain itself or from various portions 
of the body by their nerve-supply, and from this centre motor im- 
pulses are transmitted to the muscles concerned in the act of vomiting, 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 765 

and to the stomach and oesophagus. In his usually graphic manner 
Brunton has described the entire mechanism. 

By a very good diagram (see Fig. 195) the author indicates the 
afferent nerves which transmit impulses to the vomiting-centre, ex- 
citing it to action. They are : pharyngeal branches of the glosso- 
pharyngeal ; pulmonary branches of the vagus ; gastric branches of 
the vagus ; gastric branches of the splanchnic ; renal, mesenteric, 
uterine, ovarian, and vesical nerves. Fibres pass downward from the 
brain, conducting impressions to the vomiting-centre from the organs 
of special sense, from the brain-substance or its membranes when the 
seat of disease, or from central ganglia excited by emotion or imagi- 
nation. 

Fig. 195. 



LIVER AND 
GALL-BLADDER 




KIDNEY 
AND URETER 



NERVOUS CENTRE 
OF VOMITING IN 
THE MEDULLA 
OBLONGATA 

SPINAL CORD 

•--VAGUS 

PULMONARY 
BRANCHES 

SPLANCHNICS 

GALL-DUCT 



RENAL NERVES 



__.J MESENTERIC 
NERVES 



. } UTERINE 
NERVES 



The nervous mechanism of vomiting. 



From this it is seen that vomiting is a reflex act ; that its mechanism 
is quite simple ; and that a proper understanding of this mechanism 
is essential to a correct appreciation of its pathology and treatment. 
Reference has not been made to the vomiting that occurs in the initial 
stage of many fevers, and in septicaemia, uraemia and allied affections, 
and to the vomiting of hysteria. In the former it is doubtless due to 
the direct action of the poisoned blood on the centre, but it can also 
readily be seen to be due to the propagation of impulses to the centre 
from the brain that is irritated by the blood. If the phenomena of 
hysteria are due to an abeyance of the processes of inhibition, the 
occurrence of vomiting can be said to arise from the non-control, by 



766 SPECIAL DIAGNOSIS. 

higher centres, of this centre. (From "Vomiting, Physiological and 
Clinical." Trans. Penna. State Med. Soc, 1887. Musser.) 

The significance of vomiting in a given case can sometimes be deter- 
mined very readily, and sometimes it remains in doubt after very 
careful examination and questioning of the patient. In seeking for 
an explanation of vomiting it is of importance to find out the previous 
health of the patient ; whether it occurred after the patient had been 
ill for a longer or shorter time, or suddenly, when he was in apparent 
health, or whether it formed one of the initial symptoms of an acute 
disease. 

Again, inquiry should be made as to the supposed cause of the 
vomiting ; whether it was excited by the taking of food, drink, or 
medicine, or by some disgusting sight or odor. 

Further, the time of the occurrence of the vomiting should be ascer- 
tained, as well as its frequency, and whether preceded by nausea, pain 
(noting its locality), injury, coughing, jaundice, or constipation. 

The position of the patient at the time the vomiting occurs some- 
times furnishes a valuable clue to its cause. 

The effect of the vomiting is sometimes of aid in diagnosis. In 
ulcer and migraine, for example, it affords marked relief. 

Finally, the appearance and quantity of the matter vomited are 
very important. (See Objective Signs.) 

Character. Vomiting may occur occasionally, persistently, or peri- 
odically. It may be projectile and painless, or difficult and painful. 
The former is characteristic of cerebral disease or reflex vomiting ; 
the latter of local gastric disease. When vomiting occurs suddenly, 
without antecedent illness, it usually indicates some local affection of 
the stomach, or is due to some nervous impression, or marks the onset 
of some acute general disease. 

Vomiting in Gastric Disease. The local affections of the stomach 
attended by vomiting are acute and chronic gastritis (especially the 
catarrhal form), dyspepsia, ulcer, cancer, and dilatation. 

In acute gastritis there will be a history of an acute illness marked 
by severe local and general symptoms. The cause of the gastritis may 
be found to be overeating of highly seasoned or indigestible food ; abuse 
of alcohol, narcotics, or sedatives ; drinking water to which the patient 
is unaccustomed ; poisoning with such drugs as arsenic and mercury ; 
sudden changes in atmospheric conditions in susceptible persons. The 
vomiting is preceded by nausea, epigastric pain and tenderness, and 
often followed by profound prostration. 

The vomited matters consist, first, of the contents of the stomach 
(which may throw light on the cause of the attack), then of mucus, 
saliva (which has been swallowed), bile, and, in grave cases, altered 
blood. 

In chronic gastritis vomiting often occurs in from half an hour to an 
hour and a half after eating, the food being only partly digested and 
sometimes coated with mucus. It does not produce the prostration 
that vomiting in acute gastritis does, and is followed by some relief to 
the gastric uneasiness and pain. The emaciation may suggest cancer 
of the stomach. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 767 

In ulcer of the stomach vomiting is rarely absent. It occurs usually 
soon after taking food, and its occurrence affords relief to the gastric 
pain. There is nothing characteristic in the vomit unless it contains 
blood. Welch thinks that gastric hemorrhage in recognizable amount 
occurs in about one-third of the cases. 

In cancer of the stomach vomiting is an almost constant symptom, 
but it may not occur until comparatively late in the disease, or, more 
rarely, may be one of the earliest symptoms. Usually it does not 
appear until dyspeptic symptoms have persisted for some time. There 
is no uniformity in the frequency of its occurrence or in the character 
of the vomit. As a rule, vomiting occurs at a longer interval after 
taking food than in the case of ulcer, and the ejection of food does not 
give as much relief to the patient. Vomiting may occur every day or 
several times a day in the early stages, but if dilatation of the stomach 
develops, as it usually does in cancer of the pylorus, vomiting may be 
deferred for several days, and then be correspondingly more copious 
in amount. Blood, frequently altered by gastric juice so as to resem- 
ble coffee-grounds, is a common constituent of the vomit. (See Under 
Inspection.) 

Vomiting in Infections. Vomiting frequently marks the onset of acute 
diseases, especially pneumonia and the eruptive fevers said yellow fever. 
Excessive vomiting generally indicates that the case will be severe. 

Reflex Vomiting. Nausea and vomiting are excited in some persons 
by the sight of blood, or by a horrible or loathsome spectacle ; others 
are more susceptible to foul odors and disgusting tastes. 

Vomiting is frequently reflex, that is to say, irritation at some point 
is transmitted by the proper afferent nerve to the vomiting-centre and 
then reflected to the stomach. Vomiting of this character occurs in 
pregnancy, diseases of the appendix vermiformis, ovaries, uterus, bladder, 
'prostate gland, lungs, nose, eyes, kidneys, intestine, peritoneum, liver, gall- 
bladder, and bile-ducts. 

Vomiting is found to be of reflex origin when there is no local affec- 
tion of the stomach present and no general disease to account for it, 
and when a remote source of irritation can be discovered, the removal 
or mitigation of which checks this vomiting. The particular organ 
which is the source of the irritation must be determined by a careful 
physical examination guided by the indications furnished by the age, 
sex, time of occurrence, habits, and other symptoms which accompany 
the vomiting. 

The nausea and vomiting from which many women suffer during 
the early months of pregnancy are most marked on rising in the morn- 
ing ; they are aggravated if the patient has been on her feet much or 
has been subjected to any exhausting or worrying influence ; on the 
other hand, they are relieved by quiet and the recumbent posture. In 
diseases of the ovary, uterus, bladder, and prostate there are local pain, 
catarrhal symptoms, inflammation or noticeable enlargement. 

The lungs are probably not often the cause of reflex vomiting. 
Rarely, however, phthisis is so masked by gastric symptoms and vomit- 
ing as to be overlooked. More frequently it is the act of coughing 
and the effort to expel the sputa from the throat that produce the 



768 SPECIAL DIAGNOSIS. 

vomiting. Expectoration tickles the throat, and may have the same 
effect as the finger or feather in inducing vomiting. This seems to be 
the explanation of the vomiting which follows a hard spell of coughing 
in pertussis. 

Peritonitis may be suspected to be the cause of vomiting if there has 
been injury to the peritoneum from a surgical operation, or if it has 
been exposed to infection through the uterus and tubes, or from disease 
of organs surrounded by it, as the vermiform appendix. Vomiting 
may be the only symptom present except collapse. The fluid is not 
only ejected, but regurgitated, and may appear to flow from the stom- 
ach. Large amounts of fluid are discharged, clear or of a green color. 

In the vomiting due to the passage of a renal calculus or gallstone 
the colicky pains and their location definitely point to the source. 

Vomiting in Toxwmias. Vomiting is also a marked symptom of tox- 
aemias ; they produce vomiting probably by direct irritation of the 
vomiting-centre. Among such diseases are the specific fevers, notably 
scarlet fever and yellow fever ; sewer-gas poisoning ; diseases of the liver 
and kidney, which produce cholwmia and urwmia, particularly cirrhosis 
of the liver and interstitial nephritis. 

Cyclic Vomiting. This condition was described by Ley den in 1882 
as periodic vomiting. Cases in children have been recorded by Snow 
and others. Clinically, the vomiting is sudden in onset, severe, and 
consists first of the contents of the stomach, and later of acid mucus. 
There is usually a febrile reaction at the onset, but this may be absent 
in adults. The abdomen is almost invariably retracted. There is 
usually a degree of prostration which is out of proportion to the local 
manifestations, and may be dangerous. There may be narcosis, del- 
irium, or great restlessness. These gastric crises recur at intervals of 
six weeks to six months, and will recur periodically in spite of the 
utmost care as to diet. This disease is probably a gastric neurosis, 
and has analogies with migraine. There is no reason to believe that 
it is reflex in origin. It may be due to the accumulation of toxic sub- 
stances. 

The vomiting of urcemia usually occurs in the morning. It is ac- 
companied by nausea and depression. Whenever morning nausea and 
vomiting occur in an adult without obvious local cause the urine should 
be examined. Other confirmatory signs are high-tension pulse, accent- 
uation of the aortic second sound, and hypertrophy of the heart. 

Cerebral Vomiting. Vomiting due to cerebral disease is well recog- 
nized. In early life it is a characteristic feature of meningitis and 
tumor of the brain. It is likewise of moment in later life. I am 
of the conviction, however, that it is not sufficiently recognized as one 
of the first symptoms of apoplexy. True, we find that apoplexy occurs 
after a full meal, when the attack is associated with indigestion, with 
efforts at vomiting ; and I do not here refer to such cases, but to cases 
of painless, often watery vomiting, occurring without nausea and with- 
out retching. A sudden, violent expulsion of the stomach-contents, 
ceaseless, unrelieved by remedial measures, has been seen by the writer 
to precede other signs of apoplexy by from thirty minutes to twenty- 
four hours. In all cases of apoplectic character the pulse is sIoav and 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 769 

full, while in nausea and vomiting from other causes, in the aged par- 
ticularly, it is weak and feeble. Moreover, some alteration of breath- 
ing is noticed. It is either irregular, or slow, or unduly hurried. It 
proves the intimate relation of the vomiting and the respiratory centres. 
Further, strength is seen, not weakness ; in the apoplectic the face is 
congested, not pallid as in simple sick stomach. The other peculiari- 
ties of cerebral vomiting have been indicated. 

Crises. Sudden attacks of vomiting with hyperacidity, with or 
without pain, often occur in locomotor ataxia. Such attacks occur in 
other affections, as hysteria. They occur in movable kidney, and are 
known as Dietl's crises. 

Diagnosis. Vomiting is readily recognized. It is often productive 
of serious symptoms. It may cause apoplexy or cerebral congestion ; 
it may cause acute overdistention of a dilated heart, as in aortic re- 
gurgitation. If it continues for any length of time, and much fluid is 
ejected, it is attended by anuria, and rapidly followed by collapse. It 
also induces thirst. 

Flatulency. Flatulency is an accumulation of gas in the stomach 
or intestines. It is a very common source of complaint on the part of 
patients. Gastric flatulency is marked by a distention of the stomach, 
with the discomfort Avhich it occasions, and by the eructation of gas at 
variable intervals after the taking of food. When the gas is the result 
of the fermentation which accompanies the production of the fatty 
acids flatulency is frequently accompanied by pain, which is relieved 
by eructations. When the distention is great or long continued, dis- 
turbances in the action of the heart, particularly palpitation and inter- 
mittency, are likely to occur. Occasionally it interferes with the 
breathing, and, from the apprehension which this symptom and palpi- 
tation excite, faintness and inaptitude for mental and physical work 
may arise. 

Flatulence may be due to carbonic acid, which is generated and re- 
tained on account of motor deficiency. It is seen in the middle-aged 
and in the old. Air swallowed with the food or the saliva is an occa- 
sional cause. Flatulence may also be due to the regurgitation of 
pancreatic juice, as in fixation of the stomach- wall and open pylorus. 
It comes on four or five hours after eating, and is caused by de- 
composition of the carbonates of the pancreatic juice setting free car- 
bonic acid. Flatulence from bacterial fermentation is seen in dilatation 
of the stomach, and is usually continuous. It also occurs in chronic 
indigestion. Flatulence in rare instances is due to disturbance of the 
interchange of gas between the blood and the contents of the stomach. 
Normally it is known as g astro-intestinal respiration. 

Excessive flatulency is a common manifestation of hysteria. Such 
patients may complain of something rising into the throat from the 
stomach and smothering them (globus hystericus). There may also be 
tympanites, and even phantom tumor. It may be necessary to anaes- 
thetize the patient completely, to diagnosticate the latter from genuine 
tumor. 

Vertigo. The stomach is but one of a number of sources of ver- 
tigo. Some patients find by experience that certain articles of food, 

49 



770 SPECIAL DIAGNOSIS. 

such as oysters or lobsters, have to be avoided because they produce 
vertigo, although digestion is good, and more indigestible articles can 
be taken without inducing any such result. 

In other cases acute indigestion from overeating, particularly if it 
result in the development of an acid condition of the stomach, is apt 
to be accompanied by vertigo when the stomach symptoms are most 
severe. Usually the vertigo is associated with headache, more or less 
intense ; it is relieved by lying down and closing the eyes, but does 
not wholly disappear until all the symptoms gradually subside after 
free vomiting. Some persons are subject to so-called " blind " head- 
aches — headaches accompanied by dimness of vision, more or less 
mental confusion, and uncertainty of gait, possibly with staggering, and 
often with vertigo. Such headaches appear to be due to an acid con- 
dition of the stomach, and are relieved by alkalies or vomiting. 

It is difficult to separate the vertigo of chronic gastric or gastroin- 
testinal dyspepsia from that of lithsemia or latent gout. Probably 
both are due, not to any local irritation transmitted to the brain, but 
to the circulation in the blood of toxic products of digestion which 
act upon the brain. The vertigo is not so severe as in acute indiges- 
tion or acute dyspepsia, but is constant. In some patients it is asso- 
ciated with an unconquerable aversion to walking alone upon the street. 

Pain. Cardialgia is a form of discomfort in the epigastrium 
scarcely amounting to pain, but attended by heartburn or acidity. 
Gastrodynia is a violent pain spoken of as cramp or spasm of the 
stomach. The pain is transient. Gastralgia is a form of pain with 
features like that of neuralgia, occurring when the stomach is empty. 
(See Gastric Neuroses.) 

Location. Pain in the Epigastrium. Pain referred to the stomach 
is situated in the upper zone of the abdomen, below the ensiform carti- 
lage, between the ribs of the two sides, usually in the median line. It 
may be along and under the left ribs. Pain in this situation may be 
due to a number of causes : 1. To myalgia, neuritis, or neuralgia of 
the intercostal nerves, which terminate in this situation. (See Abdom- 
inal Pain.) 2. Localized peritonitis or perigastritis, which may be 
secondary to or caused by infection or injury of the peritoneum from 
disease of contiguous organs. 3. Affections of the pancreas may cause 
pain : a. Pancreatic colic, a rare condition associated with diarrhoea, 
intestinal dyspepsia, and salivation. The pain is paroxysmal, the 
attacks lasting two or three hours. 6. Pain due to carcinoma of the 
pancreas, darting or lancinating in character, associated usually with 
tumor, jaundice, and emaciation, c. Pain due to pancreatic hemor- 
rhage. It is sudden and extremely severe, attended by collapse. 4. 
Pain in this situation may be due to aneurism of the aorta or of the 
coeliac axis. It is constant, of a boring character, and may be associ- 
ated with shooting pains along the course of the lumbar nerves. The 
physical signs of aneurism are present. 5. Pain in this region may be 
due to hepatic colic. 6. It may be due to disease of the vertebrae. 
We should look for the sixth or seventh dorsal vertebra to be affected, 
hence higher up posteriorly than the area affected in front would indi- 
cate. 7. Affections of the stomach. Of these we have : a. Gastralgia 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 771 

in all its forms. (See Gastric Neuroses.) b. Acute and chronic gas- 
tritis, c. Gastric ulcer, d. Carcinoma of the stomach. To the first 
class belongs a peculiar pain which occurs in locomotor ataxia, and 
which, on account of its sudden onset, with alarming and frequently 
repeated vomiting, is known as a gastric crisis. 

Pain in the Left Hypochondrium. It may be due to a dilated stomach 
or distended colon. 

Pain of Gastric Origin. In diseases of the stomach pain is a very 
common symptom. It is of all degrees, from a mere sense of discom- 
fort or uneasiness to agony. In atonic dyspepsia there may be no local 
gastric symptoms except a feeling of weight and fulness, while in ner- 
vous dyspepsia there is usually uneasiness or discomfort after eating. 
In gastralgia the pain is characteristic : it usually comes on while the 
stomach is empty, and frequently recurs daily at the same hour. At 
first the pain is slight and easily borne, but it gradually increases in 
severity. Each succeeding paroxysm is worse than the preceding one, 
until a climax of agony is reached. In character the pain is gnawing 
and cramp-like, doubling the patient up, and after subsiding leaving 
him moist with cold sweat and in partial collapse. 

In catarrhal dyspepsia there are pain and uneasiness in the stomach 
after eating, with tenderness on pressure. If flatulence coexists, there 
will be temporary relief to the discomfort upon the eructation of gas. 

In idcer there is a more or less constant feeling of soreness in the 
epigastrium. After taking food the dull pain is aggravated and becomes 
sharply localized. Frequently there is pain in the back at the same 
point, a little to the left of the spine and between the midscapular 
region and the lumbar vertebrae. The pain usually occurs sooner after 
taking food than in the case of cancer, and is more frequently relieved 
by vomiting. Attacks of gastralgia are not rare, and the pain may 
shoot down the arm. 

In gastric cancer pain may be wholly absent throughout the entire 
course of the disease ; but, as a rule, pain is more continuous than in 
ulcer, less severe, not so sharply localized, does not come on so soon 
after taking food, and is not relieved to the same degree by vomiting. 
Paroxysms of gastralgia are not so common. 

In acute gastritis the pain and its character vary with the intensity 
of the inflammation. If due to the irritation of some toxic agent 
which has been swallowed, the pain is severe and burning ; if the 
result of imprudence in eating and drinking, the pain is of a dull, 
sickening character. In either case there is more or less tenderness on 
pressure. Sometimes, in mild cases of catarrhal gastritis, firm press- 
ure from a broad surface affords at least temporary relief to the dis- 
tress. 

Time of Pain. The significance of pain depends on the time of its 
occurrence. Pain coming on before eating or when the stomach is 
empty is due to gastralgia. It is relieved by food. When it comes 
on after eating, it is usually due to organic disease of the stomach, as 
ulcer or carcinoma ; but it may be due to neurasthenia. It must not 
be confounded with the pain that occurs from two to four hours after 
meals, caused by intestinal indigestion or some pancreatic affection. 



772 SPECIAL DIAGNOSIS. 

When the pain is diffused, it is due to hyperacidity and bacterial fer- 
mentation, as in dilatation, catarrhal gastritis, and simple indigestion. 
When localized, it is due to ulcer or cancer, and is associated with ten- 
derness. It may extend to the back. 

Alterations of Appetite. Loss of appetite, or anorexia, may be 
due to a number of diseases. It is present in all forms of organic disease 
of the stomach except occasionally in ulcer. In the majority of cases of 
this affection it is present. It may or may not be present in gastric neu- 
roses. Every one is familiar with the loss of appetite due to nervous 
impressions, as emotions, anxiety, or mental care. It is of frequent 
occurrence in disorders remote from the stomach, which modify the 
condition of the organ reflexly. In the section on Vomiting will be 
found statements showing the influence of central disease and disease 
of distant organs upon the stomach. Through the same channels and 
through the same mechanism, and hence by the same group of causes, 
loss of appetite may be produced. Loss of appetite is a constant 
accompaniment of the moderate gastritis which attends all fevers. 
Reference cannot well be made to all the conditions which induce this 
symptom. In all forms of anaemia, in all chronic wasting diseases, and 
in functional and organic disease of the nervous system the appetite is 
lost. The writer has been particularly impressed with the importance 
of determining the presence or absence of suppuration in some portion 
of the body, in all cases in which there is loss of appetite or disgust for 
food, the cause of which is not of gastric origin. 

Boulimia, or excessive appetite, sometimes occurs. It is popularly 
thought to be due to worms in children. It is a common symptom in 
the earlier periods of diabetes, and is said to be present in disease of 
the mesenteric glands. It occurs also in gastric neuroses. Perversion 
of the appetite, in which all sorts of substances are greedily swallowed, 
occurs in hysteria, dementia, and pregnancy. It is known as pica. 

Regurgitation of gases or food matter is a frequent symptom of 
gastric disorder. It is also known as belching or eructation. It may 
be limited to the discharge of gas, although sometimes imperfectly 
digested food also regurgitates. (See Rumination.) 

Regurgitation of the gastric juice alone causes an unpleasant taste, 
and the fluid is hot and acrid. The juice is usually brought up in the 
belching of gas. 

Pyrosis, or waterbrash, is a common symptom in some forms of 
dyspepsia. It may occur in the morning when the stomach is empty, 
at which time large amounts of fluid are ejected. The fluid is thin 
and watery, sometimes acid, sometimes tasteless. In other cases the 
fluid is slightly alkaline. The fluid is ejected without vomiting. 
Sometimes the discharge begins immediately after eating. The late 
Dr. Chambers thought that the fluid was saliva which was swallowed 
and retained in the lower part of the oesophagus by a spasm of the 
cardiac orifice, and when a sufficient amount was collected, gushed back 
into the mouth. Pavy and Hand field Jones believe that the fluid is 
secreted by the stomach, while, on the other hand, Roberts, who found 
the liquid to possess diastatic power, believes it to be due to saliva. 
Acid eructations from hyperacidity or fermentation occur one or two 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 773 

hours after meals. They rarely occur in dilatation, but are common 
in overfeeding. 

Palpitation. Increased action of the heart is a common symptom 
of indigestion due to flatulency or an overloaded stomach. It occurs 
in the middle period of life, in the anaemic and neurotic, in cardiac 
disease, and in those who use tea and tobacco to excess. 

Cough. Cough is a frequent symptom of gastric disorder. It may 
be due to the pharyngitis, which has been set up by acid eructations ; 
it may be mechanical, when a distended stomach presses upon the dia- 
phragm, or it may be reflex. Cough after meals in patients with 
tuberculosis or other pulmonary affection is usually due to pressure 
upon the diaphragm. 

Dyspnoea. This occurs in many cases of dyspepsia if the subject 
is the victim of asthma, is anaemic, or subject to cardiac disease. In 
asthma it is usually reflex ; in anaemia it is due to atony of the stomach 
and gaseous accumulation ; in cardiac disease it is mechanical from the 
pressure of a gaseous distended stomach. 

Hiccough, or singultus, is a spasm of the diaphragm. The con- 
tractions take place at more or less regular intervals, attended by a 
peculiar clicking sound. This sound is due to the sudden passage of 
air through the glottis. Hiccough may be a serious symptom. It 
may last but a few minutes or continue for several days. In the latter 
case it causes extreme exhaustion. Its occurrence in chronic disease 
is of bad prognostic omen. 

Drowsiness is frequently seen in dyspeptics after meals. Sleepless- 
ness is of frequent occurrence. It may be due to the irritation of food 
remaining in the stomach over night or to the absorption of toxic products. 

Constipation. This symptom will be discussed in the chapter on 
Intestinal Diseases. It is present with gastric dilatation. In pyloric 
stenosis it is always present. 

Diarrhcea. The digestion is impaired and peristalsis is in excess. 
Lienteric diarrhoea is an accompaniment of a gastric motor neurosis, 
or it may be due to the absence of HC1. In gastrectasia the fer- 
mentative products set up gastro-intestinal catarrh, which induces 
diarrhoea. 

The Data Obtained by Observation. 

The Objective Symptoms. One of the objective expressions of the 
morbid process or of altered function is seen in changes in the charac- 
ter of the contents of the stomach. The contents are obtained for 
examination when discharged from the stomach (vomit) or when re- 
moved artificially (washings). Both fluids are studied by inspection, 
including microscopical examination and by chemical and bacteriologi- 
cal examination. The sense of smell enables one to differentiate many 
varieties of fluids. Alteration of function is also seen in alteration of 
digestion, and is estimated by chemical and physiological methods. 
The activity of the digestion must be determined by ascertaining the 
duration of digestion and its degree of completeness, which depend upon 
three factors : (1) The motor power ; (2) the absorptive power ; (3) 
the digestive power of the gastric secretions. 



774 SPECIAL DIAGNOSIS. 

To secure objective data, therefore, the following are necessary : 

I. Physical examination, to determine tenderness and the size, posi- 
tion, and movement (peristalsis) of the stomach. 

II. Examination of the gastric contents. 

III. Examination of the digestive power of the stomach. 

IV. Examination of the motor power of the stomach. 

V. Examination of the absorptive power of the stomach. 

I. Physical Examination of the Stomach. Inspection.' 
Direct inspection of the stomach region often affords much positive in- 
formation. When there is much loss of abdominal fat and the stomach 
is well distended its outlines can sometimes be traced with the eye. 
The best position is behind and above the patient's head while he is 
lying down. If the lower curvature can be traced considerably below 
the navel, the stomach is almost certainly dilated, and if, at the same 
time, there is a prominent swelling in the pyloric region, accompanied 
by progressive loss of weight and cachexia, the dilatation is probably 
due to cancer of the pylorus. A marked groove extending from the 
umbilicus to the ribs, about or to the left of the nipple-line, is seen in 
cases of dilatation when the stomach has fallen. It is the position of 
the lesser curvature. The lower border is also marked by a groove 
extending in a curve from the pubis toward the first groove. 

Peristaltic waves may be seen to move spontaneously, or after tap- 
ping the region or applying an ether spray or faradism. When the 
pylorus is obstructed anti-peristaltic waves may also be seen. The 
waves of the muscular contraction begin at the cardiac end or fundus, 
and extend to the pylorus ; hence, they begin under the ribs of the 
left side and extend downward toward the right lower quadrant. They 
vary in extent with the amount of dilatation. (See page 729.) 

Distention of the stomach with carbonic oxide (see Percussion), or, 
better, with air by means of a hand-bulb syringe, frequently brings 
the outlines of tumors of the pylorus plainly into view, while at the 
same time any tumor lying behind the stomach becomes less distinct, 
and false tumors due to spasm of the gastric muscular coat vanish. Dis- 
tention also helps to map out the whole stomach and to separate it from 
surrounding viscera. It enables one to estimate the size and position of 
the stomach. Hence, by this means descent can be told from dilatation. 

Gastrodiaphany or Transillumination of the Stomach. Einhorn has 
succeeded in transilluminating the stomach by an Edison lamp fastened 
to a soft-rubber tube. The wires to the battery are carried through 
the tube. After the stomach contents have been removed the patient 
is to take one or two glassfuls of water. The apparatus after lubri- 
cation is then inserted. The examination must be made in a dark 
room. By means of gastrodiaphany the position and size of the stom- 
ach are determined, to a certain extent, and the presence of tumors of 
the anterior wall of the stomach is recognized. The results are not 
strictly accurate, however, as transillumination of the intestines is 
brought about if they are empty. The form and size of the stomach 
are not so readily brought out as the topographic relation of tumors of 
the stomach and those in the vicinity of that organ. It is of service 
in some cases to distinguish dilatation from gastroptosis. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 775 

Rontgen Light. The outline of the stomach may be observed by 
the use of X-rays, provided the patient has been given 10 or 20 grains 
of subnitrate of bismuth. 

Palpatio^. Palpation of the stomach is closely associated with 
auscultation, inasmuch as the former also elicits sounds (succussion, 
gurgling) which are helpful in diagnosis. The hand must be placed 
flat upon the abdomen and pressure made by bending the ends of the 
phalanges. To make deep palpation, gradually increasing pressure 
with a rotary movement must be employed. It may be of advantage 
to palpate in the knee-elbow position, so that deeply seated tumors, if 
movable, may fall to the abdominal wall. (See Auscultation.) 

But palpation elicits information independently of auscultation, 
chiefly in conditions of disease. Epigastric pulsation is common in 
anaemia ; in nervous dyspepsia ; in valvular disease of the heart, par- 
ticularly tricuspid regurgitation, producing a liver-pulse ; and in the 
rare cases of aneurism of the abdominal aorta. 

Increased resistance may be due to the hypertrophy of the muscular 
coat which coexists with distention of the stomach. When the stomach 
is shrunken and the resistance increased, it may be due to a diffused 
carcinoma of the walls of the stomach ; or, rarely, to the so-called 
" fibroid stomach," the atrophy and thickening of the walls being due 
to chronic gastritis. 

Increased resistance limited to the pylorus is found in carcinoma. 
The same effect produced by a tense right rectus muscle must be ex- 
cluded. 

Position of Gastric Tumors. Cancers of the pylorus are situated 
usually between the xiphoid cartilage and the umbilicus, frequently a 
little to the right of the median line ; but they may be found below 
the umbilicus, and, exceptionally, still lower down. Adhesions to 
neighboring organs commonly prevent the tumor from being moved. 
When it has formed adhesions to the liver or diaphragm it moves with 
respiration. 

As a rule, tumors due to gastric cancer are small, hard, and irregu- 
lar, and gradually increase in size. 

Non-malignant tumors are occasionally found, and also tumors due 
to adhesions around old ulcers, and to puckered scars. The latter are 
distinguished from cancerous tumors, not by the physical examination, 
but by their duration and clinical history. 

Another method of determining the position and size of the 
stomach is by internal exploration combined with external palpation. 
A bougie is introduced into the stomach and swept over its entire in- 
ternal surface, the position of the bougie being followed from point to 
point by the palpating hand. This method is not advisable when it is 
possible to make a diagnosis without it. 

Pain and Tenderness. Tenderness is elicited by palpation in gas- 
tritis, in dyspepsia, especially the catarrhal form, in ulcer, and in 
cancer. In gastritis and dyspepsia the tenderness is usually diffuse 
and is not constant ; in cancer the tenderness is usually limited to the 
seat of the tumor, but is not so marked nor so sharply localized as in 
ulcer. In ulcer tenderness is rarely absent ; even when there is no 



776 SPECIAL DIAGNOSIS. 

pain, it is very decided, and is so localized, sometimes, that it can be 
covered with the tip of the finger. Pain in the stomach from ulcer is 
chronic, circumscribed, and variously described as burning and wound- 
like. It is aggravated by palpation, and by food or drink, especially 
hot stimulating drinks, and relieved by cold, soothing drinks. It is 
accompanied frequently by pain in the corresponding vertebrae. 

Diffuse pain is met with in acute and chronic gastritis, and in cancer 
of the stomach-walls. 

Percussion. Position of the Stomach. (Plate XXXVIII., Fig. 1.) 
The stomach does not occupy a fixed position, and is a distensible 
organ. It is depressed by downward pressure of the diaphragm in 
deep inspiration, by emphysema, left pleural effusions, enlargements 
of the liver and spleen, and tight lacing ; it is raised by any causes 
which greatly distend the bowels or peritoneal cavity — tympanites, 
peritoneal effusions, tumors, etc. Moreover, after food is taken, the 
stomach is distended and its position changed, being rotated anteriorly 
from below, the greater curvature rising and looking more forward, 
while the anterior surface has a more upward presentation. 

The cardiac orifice of the stomach is fixed by its passage through 
the diaphragm and by peritoneal attachments which it receives there. 
It is behind the sternal insertion of the left seventh rib. The pylorus, 
on the contrary, is freely movable when the stomach is empty ; it is 
nearly in the median line, but when the stomach is full it is pushed 
several inches to the right ; it lies between the right sternal and para- 
sternal lines, on a level with the tip of the xiphoid cartilage. 

Obrastzow (JDeut. Arch, fur Min. Medicin, Bd. xliii. 5, 417-456) 
divides the space between the navel and the xiphoid cartilage into 
three equal parts, and says that the lower border of the stomach, both 
in men and in women, is in the lower or supra-umbilical third. 

In children under fifteen years the lower border rarely extends to 
the umbilical line ; after fifty years, on the contrary, it often extends 
below the navel. In conditions of bad nutrition it falls nearly to the 
navel. 

According to Pacanowski and Wagner, the upper border of the 
stomach, in the left parasternal line, lies at the lower border of the fifth 
rib or in the fifth intercostal space, rarely at the fourth rib or in the 
sixth intercostal space. In the left nipple-line it lies from the fifth 
interspace to the sixth rib, occasionally in the fourth interspace or at 
the seventh rib. In the anterior axillary line it lies at the lower 
border of the seventh or eighth rib, rarely above the sixth rib, never 
under the eighth rib. 

Traube has called special attention to the left lower portion of the 
thorax which projects over the stomach, " the half -moon-shaped space." 
The upper limit is a crescentic line starting from the sternum in the 
sixth interspace and extending, in a curved line corresponding approx- 
imately to the curve of the rib, to the axillary line. It is known as 
" Traube's line." In health this space gives a tympanitic note, unless 
the stomach or transverse colon is full, or the omentum very fatty. 
In left pleural effusion it is dull. (See Diseases of Lungs.) 

A part of the anterior portion of the stomach and its lower border 



PLATE XXXVIII 



FIG. 1. 




\> 



Solid red 



Normal Position and Displacements of the Stomach. 

line _Normal position of distended stomach. Bine line-Atonic 
clililation. Dotted reel line— Gastroptosis. 



FIG 2. 







Tumorj^ 



~J \~) Sjdash y/;; 



Mv 



N3 



^ 



o 



Carcinoma of the Stomach with Pyloric Stenosis. 
Metastases in the Liver. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 777 

can be determined by percussion. Ordinarily, the most suitable posi- 
tion for examining the stomach is the recumbent one, with the knees 
drawn up, so as to relax the abdominal muscles. 

The stomach contains air at all times, but the amount varies greatly. 

The percussion-note is tympanitic, high in pitch, frequently with a 
metallic ring ; its quality is peculiar — " stomach tympany. " 

The percussion-area of the stomach is increased (1) by causes exter- 
nal to the stomach ; contraction of the liver, old pleurisy with retrac- 
tion of lung, emphysema, former pregnancies, bad nutrition, and 
tumors pulling down the stomach ; (2) by intrinsic causes ; distention 
of the stomach. 

Conversely, the percussion-area is diminished by causes external to 
the stomach ; enlargement of the liver and spleen, left-sided pleural 
effusion, pneumothorax, and hypertrophy of the heart. 

Actual diminution in size of the stomach itself is difficult to demon- 
strate clinically with certainty. If upon inflation the great curvature 
remains at a higher level than 3 to 5 cm. above the umbilicus, diminu- 
tion in size is highly probable. But even then the lower border may 
be prevented from descending by adhesions to surrounding viscera. 

Enlargement of the stomach is generally due to dilatation, and is 
best marked clinically by a low position of the greater curvature. 
Dilatation of the stomach, according to Boas, can be separated from 
descent of the organ only when the greater curvature is more or less 
below the level of the navel, and when the greatest height of the stom- 
ach exceeds 10-14 cm. (4 to 5 J inches). But descent and dilatation 
are frequently present together. (Plate XXXVIII., Fig. 1.) It 
must not be forgotten that when there is descent the normal tympany 
is lowered and the tympanitic area above the ribs is replaced by dulness. 

Sometimes when the stomach is distended by air the right margin 
will be seen to extend far beyond the ordinary limits. Michaelis 
points out that this may be due to defective motor power, especially 
if the right margin is more than 9 cm. from the median line. The 
distention to the right is due to actual enlargement and not to disloca- 
tion. The author believes that dilatation of the antrum of the pylorus 
causes this enlargement. Enlargement of the stomach downward is 
usually associated with good motor power, whereas enlargement to the 
right is an indication of feeble motor power. 

Auscultatory percussion is a most satisfactory method of determining 
the borders of the stomach and its size. Its area can readily be de- 
fined from that of the liver, spleen, and colon : First, with the stomach 
normal ; second, inflated by gas ; third, filled with fluid. It is well 
to determine the results in the recumbent posture, and then in the 
upright, so as to determine if the stomach falls from its normal posi- 
tion. Liquid maybe injected through the stomach-tube, or the patient 
may drink successive portions, percussion being employed after each 
amount (eight ounces) taken. After the site of the dulness is fixed, 
have the patient lie down. The fluid falls backward and the air in 
the stomach comes anteriorly ; the dull note is replaced by a tympan- 
itic note. The change is a sign the fluid is in the stomach, and serves 
to distinguish stomach from colon tympany. The force required for 



778 SPECIAL DIAGNOSIS. 

percussion should be very light ; indeed, a fillip with the nail is some- 
times sufficient. It may even be well to allow the blow to glance from 
the surface, as the perpendicular stroke brings out the general abdomi- 
nal resonance. The use of coins is sometimes of advantage. In dila- 
tation of the stomach the percussion-note sometimes varies in tone over 
the viscus from dull to tympanitic, or vice versa, because the organ con- 
tracts under the influence of the blows. Some have described a clink- 
ing percussion-sound, not unlike that of the " cracked pot," over the 
thorax. 

Auscultatory friction is also employed in the same manner as auscul- 
tatory percussion, while rubbing the finger tips over the surface lightly. 
As long as the rubbing is made over the hollow organ over which the 
stethoscope is placed, and not moved more than two inches from it, 
the friction is heard distinctly. 

In order to separate stomach tympany from that of the colon, which 
resembles it, the stomach may be distended with gas, while the colon 
contains solid or liquid matter ; or, if the colon be filled with gas, the 
patient may be allowed to stand and drink a glass or two of water. 
In either case the contrast between a dull and a clear note marks the 
boundary between stomach and colon. 

Ziemssen recommends carbonic acid (developed by mixing sodium 
bicarbonate and tartaric acid) to distend the stomach ; the quantity 
employed for adult men is seven grammes of bicarbonate of soda and 
six grammes (one and one-half drachms) of tartaric acid. Adult 
women should receive one gramme less of each. 

As carbonic acid sometimes causes an uncomfortable oppression, 
ordinary air is preferred by some. It can be forced in by a hand- 
bulb syringe attached to an ordinary stomach-tube. The percussion- 
note over tumors of the pylorus is imperfectly tympanitic. Welch 
describes it as " tympanitic dulness." Less frequently it is dull, and 
rarely it is flat. 

Auscultation. Auscultation can determine whether or not there 
is obstruction at the cardiac orifice. On listening over the oesophagus 
with the stethoscope, when the patient is swallowing a liquid, a spurt- 
ing sound is heard, followed in from five to ten or twelve seconds by 
a second sound, which marks the escape of the fluid from the cardiac 
orifice of the oesophagus into the stomach, so-called " deglutition-mur- 
mur." When there is obstruction of the cardiac orifice the second 
sound may be delayed as long as a minute. 

When the stomach is partly filled with fluid a succussion or splashing 
sound can be produced by moving the patient quickly from side to 
side, or by quickly compressing the stomach and allowing it to rebound 
again immediately. Such compression may be made alternately, first 
in the neighborhood of the fundus of the stomach and then in the 
region of the umbilicus. Both hands should be employed. The 
splashing sounds are also developed by rapidly tapping, with the finger 
tips held perpendicularly, the region between the ribs and the trans- 
verse umbilical line on the left side. The ear need not be applied to 
the body, but kept near by while the movements are made. Such 
sounds are abnormal if they are heard long after digestion should be 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 779 

completed and the stomach empty. If they are heard more than three 
hours after a light, or six hours after a full meal, it indicates slow 
digestion or deficient motility, and gives the approximate position of 
the lower boundary of the stomach. 

Normally, after drinking fluids, a splashing sound is not developed 
lower than the umbilical line. If it is heard below this line, it is an 
indication of dilatation or of deep position of the whole stomach. Dil- 
atation is very probable if the splashing sound is heard below the navel 
in a fasting stomach. A good idea of the extent and location of the 
splashing, and hence of the lower boundary, can be secured, if aus- 
cultation is conducted when inflation is practised with air. 

Furthermore, this sound is a sign of atony. If 50 to 100 grammes 
of water be swallowed, no splashing sound is heard unless there is 
atony of the stomach-walls ; but, if the atony is pronounced, a smaller 
quantity will be sufficient to develop the sound. It is to be remem- 
bered that the splashing sound of itself does not indicate disease. It 
is significant only when taken with other signs, and also when it is 
found after more than one examination. 

II. Examination of the Gastric Contents. Either the con- 
tents are secured with a stomach-tube or the vomitus is examined. 

Mode of Procedure. 1. A test-breakfast (Ewald), or a test-dinner 
(Leube), is administered, or the fasting stomach contents removed. 
EwakVs test-breakfast : It consists of one or two ounces (35 grammes) 
of bread and a cup of tea (j- litre), or the same amount of water. 
Leube-Riegel test-dinner : A large plate of soup (400 c.c), a large por- 
tion of beefsteak or other meat, some potatoes, and a roll are taken, 
and examination is made three or four hours after the meal. (See 
Boas' Meal. Lactic Acid.) 2. Remove the contents of the stomach 
one hour after breakfast is taken, by aspiration or by expression. 
Aspiration consists in the withdrawal of the stomach-contents by suc- 
tion ; either with the ordinary stomach-pump, by means of a bottle 
exhausted of air, as employed for paracentesis, and connected with the 
stomach-sound, or by connecting the sound with a hand-ball aspirator 
or Politzer bulb. 

Expression consists in compression by the abdominal muscles, as if 
straining in defecation. The patient takes a deep inspiration and then 
contracts the muscles as above. If the tube is long enough it can be 
bent, so as to assist expression with siphonage. 

Aspiration is less disagreeable to the patient, and is necessary when 
the stomach-contents are not fluid enough to flow easily. 

Expression is not to be employed when there are old ulcers, ulcer- 
ating carcinoma, phthisis with antecedent haemoptysis, or a disposition 
to menorrhagia. 

These methods supply the most reliable information of the condition 
of the stomuh and its secretions ; because, when once withdrawn, the 
character of the secretions can be ascertained accurately and the quan- 
tity measured ; moreover, being able to choose the time of examination, 
we can decide whether or not what is found corresponds with health, and 
if not, in what particular it indicates disease. These methods permit a 
diagnosis to be made before other methods supply sufficient data. 



780 SPECIAL DIAGNOSIS. 

A soft-rubber tube, with two good-sized openings near its distal ex- 
tremity, should be selected. Stockton suggests a tracing of rings 
around the tube one inch apart, beginning twenty inches from and 
ending thirty inches from the lower extremity, for the purpose of 
measuring the length of the tube inserted. In healthy adults the dis- 
tance from the incisor teeth to the lower border of the stomach is about 
twenty-two inches. In dilatation it may be from twenty-four to 
thirty. The distance is partly determined by success in the siphon- 
age. If the return flow of fluid does not take place, it is well either 
to withdraw the tube or push it further on ; for, if too long, it may 
curve above the level of the fluid, or, if too short, it may not reach 
the fluid. 

After the tube is moistened, oiled, or coated with the white of an 
egg, the patient should be seated, and the tube at once passed to the 
back of the pharynx, and, with or without guiding by the finger, 
pushed toward the oesophagus. It is at once grasped by the oesopha- 
gus or lower pharynx, and, if the patient is instructed to swallow and 
to breathe slowly, it is rapidly carried downward by deglutition. 
Mucus that accumulates in the mouth after the tube is passed should 
be allowed to dribble outward and not be swallowed. It is often of 
advantage to reassure the patient by having him pronounce the letter 
" a " or some small syllable. It is not necessary to extend the head 
backward. The tube is then attached to the apparatus used for para- 
centesis, or to a tube entering a bottle in which a vacuum is created by 
an ordinary rubber bulb apparatus ; or to the aspirator of Boas, which 
is a modification of the ball-syringe. A valve is placed between the 
stomach-sound and the syringe. 

If a hard tube is used, it must be guided by the operator, who 
should stand back of the patient, supporting the head, which should 
not be thrown too far backward. The tube can be passed by the oper- 
ator seated in front of the patient. This kind of tube is used with 
the stomach-pump. 

Normal Gastric Contents. The amount of fluid, after digestion 
of a test-breakfast m has continued for one hour, is from 30 to 40 c.c. 
After filtering the filtrate is clear, yellow, or yellowish-brown in color. 
If the digestion is normal, the fluid should contain free hydrochloric 
acid and no lactic acid. It should also contain pepsin, rennin (the 
milk-curdling ferment), and organic acids. Albuminoids should be 
converted into proteoses and peptone, and starches into achroodextrine, 
dextrose, or maltose. 

Physical and Chemical Examination. The steps taken are 
as follows : 

A. Physical examination : 

1. The reaction. 

2. The odor. 

3. The character and quantity. Inspection. 

B. Chemical examination. 

It is to be observed that perfect familiarity with the products of 

and the length of time required by normal digestion is very essential. 

1. Reaction. The normal reaction of the contents of the stomach 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 781 

is usually acid, from the hydrochloric acid of the gastric juice. It 
may be alkaline in cases of hemorrhage, or in the vomiting known as 
waterbrash. 

2. Odor. The odor is sour normally, but it may be aromatic from 
the presence of the fatty acids, fecal in obstruction of the bowels with 
fecal vomiting, and, finally, may indicate the nature of poisonous in- 
gesta — ammonia, phosphorus, carbolic acid. The dark, frothy mate- 
rial from a dilated stomach is of a foul, yeasty odor. 

3. Inspection of the Stomach-contents. By ordinary inspec- 
tion the quantity and the charade?* of the vomitus or stomach-contents 
are noted. With the aid of the microscope the various micro-organ- 
isms are sought for. In this manner most valuable information as to 
the digestive, motor, and absorptive power is ascertained. Not only 
do we learn whether digestion has taken place or not, but also the 
variety of food that is undigested— albuminoids or hydrocarbons. 

The Quantity. Fasting Stomach. If a person has taken no food or 
drink between the evening meal and the following morning, the 
stomach should not contain more than three and one-half fluidounces ; 
more than this is abnormal. 

The Character. By it we learn the digestive power. If undigested 
food is found after digestion should be normally completed, there is 
deficient digestive energy. No undigested food should be found longer 
than six or seven hoars after an ordinary meal of mixed foods. 

By inspection of the gastric contents we learn much regarding the 
motor power. Boas states that an abnormally great quantity of solid 
matter and a small amount of chyme indicate an abnormal retention of 
the latter, which is usually brought about by motor weakness (atony, 
dilatation of the stomach), or dilatation in conjunction with insufficient 
absorptive power. Sometimes, when there is a large residue in the 
stomach, the contents separate into three layers. The uppermost is 
mucus or undigested food ; the second, generally the thickest layer, 
consists of fluid ; and the lowest layer is chyme. Such a formation, 
he says, points to abnormally long retention as the result of stenosis 
and consecutive dilatation, or to motor weakness. 

The stomach should be empty much sooner if only starches are 
taken, as in Ewald's test-breakfast. One hour after the administra- 
tion of a test-breakfast of 35 grammes of white bread and 300 grammes 
•of water there should remain 40 c.c. Hence, if after such a break- 
fast there is found a much greater quantity, then motor or absorptive 
insufficiency may be considered to exist. A filtrate of 100 to 300 c.c. 
is very probably due to organic obstruction to the outflow, stenosis of 
the pylorus, adhesions, or dislocation of the pylorus. Of course, to 
make sure that the stomach contains nothing at the time of giving the 
breakfast, it must first be emptied. The character of the food taken 
is observed, as undigested particles may be seen in the contents. 

We can discover by inspection if food is brought up by vomiting or 
regurgitation. Regurgitation of food from the oesophagus can be told 
from vomiting by the appearance of muscle-fibres, if meat has been 
taken. If it is vomited, the fibre is in a state of disintegration ; if 
not, it is whole. 



782 SPECIAL DIAGNOSIS. 

Mucus is found in small quantity normally, but is increased in 
catarrhal affections of the mouth, throat, or stomach. When its source 
is the mouth, saliva also is generally present. Mucus is recognized by 
its stringy, tenacious character. Chemical diagnosis. Add the mucus, 
gently shaking, to cold water ; pour off the supernatant water ; add 
a little liquor potassse. The mucus is dissolved by the alkali. To 
the solution add acetic acid ; a precipitate is formed which is insol- 
uble in an excess of acetic acid. In this manner mucus is distin- 
guished from the precipitate of syntonin, as the latter is soluble in 
an excess. Pigmented mucus in vomitus is usually from the bronchial 
tubes. 

Bile and intestinal juice may be regurgitated into the stomach as the 
result of violent emesis, or when the pylorus is much relaxed, or in 
stenosis of the duodenum below the common duct ; bile is then present 
in large quantity if the stomach is dilated. 1 Bile is recognized by the 
usual tests (see under Examination of Urine), and intestinal juice by 
its peculiar properties and the presence of leucin and tyrosin. Absence 
of bile in the vomitus is an indication of pyloric stenosis. 

Blood is found in ulcer ; cancer ; acute, especially toxic, gastritis ; 
injuries to the mucous membrane from the use of the sound for expres- 
sion, and violent retching. It is also common in cirrhosis of the liver, 
and may occur in purpura, peliosis rheumatica, the hemorrhagic 
diathesis, and in yellow fever. Blood mixed with gastric mucus may 
come from the lung, the act of coughing having excited vomiting. 

If the blood is unaltered, it can be distinguished from all other sub- 
stances by microscopic examination. Occasionally the blood has the 
appearance of coffee-grounds. The hemorrhage has taken place slowly 
under these circumstances. In fact, the more rapid the bleeding the 
brighter the red color of the blood. The hcemin test serves to distin- 
guish it. The suspected material is filtered and a little of the nitrate 
evaporated in a watch-glass ; when dry a small portion is mixed with 
finely pulverized salt upon a glass slide ; it is then covered with a 
cover-glass and one or two drops of glacial acetic acid allowed to flow 
under the cover-glass. The acetic acid is evaporated by slowly heat- 
ing the slip over a small flame, and when dry a few drops of water 
are allowed to flow under the cover-glass, to dissolve the salt. If the 
vomit contained blood, brown rhombic crystals of hrenrin (hydrochlo- 
rate of hsemin) will appear under the microscope. As they are very 
small, a magnification of about 300 diameters will be necessary to 
bring them readily into view. The guaiacum test may be fallacious, 
as the same color-reaction takes place when bile or saliva or a starch, 
like potato, is in the test-liquid. It is performed as follows : Add two 
or three drops of the tincture of guaiacum to a small portion of the 
gastric contents in a test-tube and pour ozonic ether on the surface. 
When the liquids meet a blue color develops. Bile may be distin- 
guished from blood by Gmelin's test for the former — color-reaction 
with nitric acid. If blood is present in the stomach-contents, it may 
be detected by the test for iron. To the gastric contents, " coffee- 

1 Hochhaus. Berlin, klin. Woch., 1891, No. 17. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 783 

grounds/' in a porcelain capsule, add a small quantity of potassium 
chlorate and a few drops of a strong acid, HC1. Heat over a flame 
and add a few drops of a 5 per cent, solution of potassium ferrocya- 
nide. If iron is present, Prussian blue is formed. 

Pus is rarely present in sufficient quantity to be detected by the 
naked eye, but it sometimes occurs in phlegmonous gastritis and when 
an abscess has ruptured into the stomach. In microscopic amounts 
it may be found in severe catarrhal affections. Pus may be in 
the vomitus and yet come from the lungs. It is usually a muco- 
pus, and is told by the pigmented pellets or strings of mucopurulent 
material. 

Fecal matter is vomited in complete obstruction of the bowels, and, 
according to Vierordt, in severe diffuse peritonitis. It is recognized 
partly by its appearance and partly by its odor. 

Worms are sometimes vomited ; the round worms not so very infre- 
quently ; oxyurides and ankylostomata rarely. 

Fig. 196. 




Microscopical appearance of stomach-contents. 
1, red blood -corpuscles ; 2, leucocytes; 3, squamous epithelium; 4, fat-globules; 5, starch gran- 
ules; 5', starch changed by action of the gastric juice ; 6, muscular fibre ; 7, sarcinse ventriculi ; 
8, fat-crystals ; 9, piece of orange ; 10, phosphatic crystal ; 11, yeast fungi ; 12, bacilli and micrococci' 



Microscopical Examination. The illustration (Fig. 196) shows the 
various matters which may be found in vomited matter. Briefly, they 
are columnar and squamous epithelium ; white blood-corpuscles acted 
on by gastric juice ; red blood-corpuscles. The corpuscles are usually 
isolated. The red are rarely perfect, and in the white little more than 
the nucleus remains. From the food we may also find muscle-fibres, 
fatty globules, and fat-needles, elastic fibres and connective tissue, 
starch-granules, and vegetable cells. Muscle-fibres are recognized by 
their transverse striation. Fat-globules are soluble in ether, and are 
recognized by their refracting powers. Starch-granules stain blue 
with iodo-potassic-iodide solution. 

In addition, fungi of many forms are found, as the mould-fungi ; 



784 SPECIAL DIAGNOSIS. 

the yeasts (torulse), and fission-fungi. The latter are recognized after 
staining by the iodo-potassic-iodide solution, which colors them blue. 
The most important fission-fungi are the sarcinse ventriculi. They 
are of a dark gray tint, stain mahogany-brown to reddish-brown with 
the above-mentioned solution, and resemble in shape corded bales of 
goods. (See Bacteriological Diagnosis.) The torulce and sarcince are 
present when fermentation is in progress, and hence indicate delayed 
digestion from motor insufficiency or deficient digestive energy. 

B. Chemical Examination. A chemical examination is made to 
determine (1) the presence of free acids ; (2) the degree of total acidity 
of the stomach-contents ; (3) the presence of free HC1 ; (4) the presence 
of lactic acid ; (5) the presence of volatile acids ; (6) the presence of 
products of digestion and the digestive power ; (7) the presence of 
pepsin ; (8) the presence of rennin ; (9) the carbo-hydrates. Hydro- 
chloric acid is the normal acid of the gastric juice. Normally lactic 
acid is found during the first half-hour of digestion, when starches 
have been taken. When only meats have been taken lactic acid is 
not found early in digestion. The secretion of hydrochloric acid is not 
delayed until then, but is at first combined, and cannot be detected 
as free acid until half or three-quarters of an hour afterward. 

1. Free Acids. The most sensitive test for free acids is Congo red. 
Filter-paper soaked in a saturated solution of the dye and allowed to 
dry is turned a deep blue if free acid is present. Prepared with a 
weak solution, the filter-paper is turned to a light blue by HC1 and 
violet by organic acids. Wolff * was able to detect one part of HC1 
in 20,000 parts of water. When no reaction is obtained, therefore, 
entire absence of acidity may be assumed. 

Benzo-purpurin test-papers are made as follows : Soak strips of 
filter-paper in a saturated solution of benzo-purpurin and dry. They 
are purple. If hydrochloric acid is present they are turned dark blue. 
The color is not removed by shaking with ether. If organic acids 
(butyric or lactic) are present, it is turned brownish-black, but the 
color is removed by shaking with ether. Von Jaksch states that if 
hydrochloric acid and the organic acids are present a brownish-black 
color is also produced, hence the dark blue and the volatile brownish- 
black reactions only are important. 

The presence of free acids, as indicated by the Congo red or benzo- 
purpurin tests, shows that : 

a. HC1 — inorganic acid — may be present alone. 

6. Lactic, butyric, or acetic acid — organic acids — one or all, may be 
present without HC1. 

c. HC1 and one or more of the organic acids may be present together. 

Free acidity may be due (1) to fixed acids— hydrochloric or lactic 
acid, fixed acidity ; (2) to volatile acids — butyric or acetic acid, volatile 
acidity. 

2. The Total Acidity. This is determined by titration. The 
stomach-contents must be well shaken ; if there is mucus in excess, it 
must be strained off through coarse muslin. Fill a Mohr's burette 

1 Trans. Philadelphia County Medical Society, 1889, vol. x. p. 305. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 785 

with a decinormal solution of caustic soda. 1 To 10 c.c. of the filtered 
gastric fluid add two drops of a saturated alcoholic solution of phe- 
nolphthalein. Allow the caustic-soda solution to drop slowly from the 
burette into the fluid, until a faint rose-red color is produced which does 
not disappear on shaking. The color is produced by the action of 
the alkali on the phenolphthalein. Four to 6 c.c. of the caustic soda 
solution are required to neutralize the acid in normal digestion. The 
degree of acidity is expressed in percentage. Thus if 4 c.c. neutralize 
10 c.c, the total acidity will amount to 40 per cent., or if 6 c.c. are 
required, to 60 per cent. 

If more or less than the amount just indicated of the alkaline solu- 
tion is required to neutralize the acid, the total acidity is increased or 
diminished, and hence is abnormal. 

Topfer's method : To 10 c.c. of stomach-contents in a beaker, add 

3 to 4 drops of a 1 per cent, solution of sodium alizarin sulphonate, 
then add a decinormal solution of sodium hydrate until a violet tint 
appears corresponding to the hue produced by adding 4 drops of 
alizarin solution to 5 c.c. of a 1 per cent, solution of sodium carbonate. 
The solution reacts to all factors producing gastric acidity except com- 
bined HC1. 

Martin recommends the following modification of the above : " To 
20 c.c. of the stomach-contents add three or four drops of a saturated 
alcoholic solution of phenolphthalein, and dilute with water to 300 
c.c. Place 150 c.c. of this mixture in each of two flasks, and place 
them side by side on a sheet of white paper. To one of the flasks add 
decinormal solution of sodium hydrate until a red color appears ; the 
exact time of appearance can be determined by comparison with the 
liquid in the other flask. When a pinkish tinge appears the acid 
liquid is neutralized. A control estimation may be made with the 
second flask." 

Ewald's method of expressing the total acidity is by a number. 
The number is the same as the quantity of decinormal sodium hydrate 
solution requisite to neutralize 100 c.c. of the gastric contents. Thus 
if 50 c.c. of the soda solution neutralized 100 c.c. of the stomach-con- 
tents, the acidity of the latter would be expressed by the figure 50. 
The figures can be converted into terms of hydrochloric acid, as a deci- 
normal solution of sodium hydrate is a liquid of a constant strength, 
100 c.c. of which exactly neutralize 0.365 gramme of hydrochloric 
acid. It may be expressed in terms of hydrochloric acid. If 50 c.c. 
of decinormal sodium hydrate are required to neutralize 100 c.c. of the 
stomach-contents, this would be equal to 0.18 gramme per cent, hydro- 
chloric acid, as 3.65 grammes hydrochloric acid are neutralized by the 

4 grammes of soda in a litre (1000 c.c.) of the decinormal solution. 

3. Free Hydrochloric Acid. The gastric contents are now 
filtered. Tropceolin 00 is declared by Boas to be an absolutely certain 
test for HC1. A saturated alcoholic solution is of an orange-yellow 

1 Decinormad solution of sodium hydrate is of the strength of 4 grammes of 
pure sodium hydrate to the litre of distilled water. The sodium hydrate must be 
pure and made from sodium. This weight of sodium hydrate (4 grammes) will exactly 
neutralize 3.65 grammes of hydrochloric acid. 

50 



786 SPECIAL DIAGNOSIS. 

color. Three or four drops of it are placed in a white porcelain dish 
and spread upon the sides by rotating it. The same amount of the 
fluid to be tested is then allowed to trickle down the sides of the dish 
and intimately mixed with the tropseolin. (Or evaporate the dye to dry- 
ness and then add the suspected liquid.) Upon heating the dish over 
a small flame splendid lilac-blue to blue streaks, characteristic of HC1, 
will appear if that acid is present. No organic acid gives the same 
color. 

Tropseolin paper is turned brown by gastric juice containing HO, 
the brown changing to blue upon the paper being heated. Organic 
acids give a brown color also, but it disappears upon heating. 

Topfer's test for the detection of free HC1 is as follows : Dimethyl- 
amidoazobenzol is employed in a 0.5 per cent, solution of alcohol. 
To a few cubic centimetres of filtered stomach-contents one to four 
drops of the reagent are added in a test-tube or beaker. If hydro- 
chloric acid is free a rose-red color is produced when the filtrate is 
added to the reagent. The drug reacts to HC1 only when the latter 
is in a free state. Its reaction is not interfered with by salts, peptone, 
glucose, chloride of sodium, or starch. If organic acids are present 
in a concentration of from 0.5 to 0.8 per cent, a reaction may be 
brought about, providing albumin or peptone is present. 

Phloroglucin vanillin, introduced by Giinzburg, is also a very sensi- 
tive test for HC1. The following combination is said by Boas to be 
more sensitive than the ordinary one, which contains only 30 grammes 
of absolute alcohol : 

Phloroglucin . . . . . . 2.0 (gr. xxx). 

Vanillin 1.0 (gr. xv). 

Alcohol (80 per cent ) .... 100.0 (fgiij). 

Three drops are put into a porcelain dish and an equal quantity of 
the stomach filtrate. Upon cautious heating over a small flame a beau- 
tiful carmine surface is formed, especially at the edges. The same 
color is not produced by inorganic acids. Filter-paper soaked in it and 
moistened with a few drops of stomach-filtrate, containing HC1, 
changes on heating to a beautiful carmine, which is unaltered upon the 
addition of ether. Gunzburg's original test is employed with the same 
solution, except that 30 parts of alcohol are used. One drop of the 
solution and one drop of the fluid to be examined are evaporated to 
dryness on a water-bath. The appearance of a rose-red color indicates 
the presence of hydrochloric acid. 

Congo-red Test. Boas' method is a modification of that of Mintz. 
Ten c.c. of the gastric fluid are shaken with 100 c.c. of ether until 
organic acids are removed. The Congo-red test is then employed 
until the grayish-blue discoloration cannot be secured. 

Boas' Resorein Test. Dissolve 5 grammes (gr. lxxv) of resorcin 
and 3 grammes (gr. xlv) of cane-sugar in 100 c.c. (f§iijss) of weak 
spirit. Apply the test in exactly the same way as Gunzburg's. A 
similar rose-red coloration, if free hydrochloric acid be present, is pro- 
duced. It is the cheapest solution that can be employed. 

Caution. In testing for the presence of HCl it is better to give the 
patient a meal which is known to be digestible within a certain time 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 787 

by stomachs in a normal state, otherwise HC1 may appear to be absent, 
because it is still combined with albuminoids. Ewald's test-breakfast 
is the simplest. In one hour the contents of the stomach may be aspi- 
rated and tested for HC1. 

Amount of Free HCL If by previous tests HC1 is found alone, its 
percentage is easily calculated. To a measured quantity of the gastric 
fluid add, drop by drop, from a burette a decinormal alkaline solution 
until the acid is neutralized. This can be determined by checking 
the titration from time to time, and examining with Gimzburg's reagent. 
One c.c. of the alkaline solution is equivalent to 0.003646 HCl, the 
limit of Giinzburg's reaction. Multiply the number of c.c. required 
to neutralize 10 c.c. of the gastric solution by 0.003646, and again by 
10, the result will be the percentage of acidity. If 6 c.c. are used, the 
percentage will be 6 X 0.003646 X 10 = 0.218, within the normal 
range, which is from 0.14 to 0.24 per cent. Gunzburg's test can be 
used to estimate the quantity of HCl. This is applied by diluting the 
stomach-contents until the test is not responded to. In health the 
limit of response is found when one part of HCl is found in 20,000 
parts of the fluid. In abnormal conditions, when the gastric fluid is 
diluted one-half, the proportion is 2 to 20,000, or 1 to 10,000. If the 
fluid is diluted to ten times its original strength, it is 10 to 20,000, or 
1 to 2000. 

The following method is reliable and easy of employment. To two 
or three drops of Topfer's solution of dimethylamidoazobenzol are added 
10 c.c. of gastric contents, and a decinormal soda solution allowed to 
flow in, drop by drop, until a yellow color takes the place of the red. 
The number of c.c of solution of soda which will neutralize the free 
HCl in 100 c.c. of stomach-contents is multiplied by 0.00365. The 
result is the percentage of HCl. If 4 c.c. of soda solution is required 
to remove the red color, multiply 0.00365 by 40, the number equals 
0.14 per cent, free hydrochloric acid. 

4. Lactic Acid. If the stomach-contents are colorless, apply the 
following tests ; if they are yellowish, make an ethereal extract, as 
described below, and then use the tests. Its presence may be deter- 
mined by Uffelmann's reagent : Mix one drop of pure carbolic acid 
with five drops of a dilute solution of neutral ferric chloride. Add 
sufficient water to render the whole of an amethyst-blue color. To 
this add a few drops of the gastric fluid. A mere trace of lactic acid 
will change the blue to a light yellow or greenish yellow. The test 
for lactic acid is simulated when phosphates, glucose, or alcohol are 
present in the gastric juice. The lactic acid should be removed by 
extracting with ether, as follows : 50 c.c. of gastric contents are re- 
duced to 10 c.c. by heat in an evaporating-dish over a water-bath. 
After the concentrated solution cools add 50 c.c. of ether. The vola- 
tile acids are driven off by heat, the lactic acid is dissolved by ether, 
and hydrochloric acid remains in the residue. Apply the test for lactic 
acid to the ethereal extract if it is acid. The following is more deli- 
cate : Add one drop of liq. ferri perchloridi to 50 c.c. of water ; add 
suspected solution ; the presence of lactic acid causes a yellow coloration. 

Boas uses the following : When a substance containing lactic acid 



788 SPECIAL DIAGNOSIS. 

is heated with oxidizers, such as manganese dioxide and sulphuric acid, 
the lactic acid is decomposed into formic acid and acetic aldehyde ; the 
latter is detected by the formation of iodoform with an alkaline solu- 
tion of iodine ; peptone and alcohol, which react similarly, are elimi- 
nated by concentrating the nitrate to a syrup. As carbohydrates also 
yield aldehyde when treated with oxidizers, a watery solution of an 
ethereal extract of the condensed gastric nitrate of a trial-meal free from 
lactic acid must be used. 

Arnold (Joum. Am. Med. Assoc, Chicago, 1898, vol. viii. p. 21) 
gives a new test for the detection of lactic acid in the stomach-con- 
tents. 

a. 0.2 c.c. saturated alcoholic solution of gentian-violet in 500 c.c. 
of distilled water. 

b. Tinctura ferri perchloridi (U. S. Pharm., 1890), 5 c.c. ; distilled 
water, 20 c.c. 

A drop of solution b, added to 1 c.c. of solution a in a porcelain 
basin, gives a blue color, which changes to a green or yellow-green on 
the addition of a few drops of filtered stomach-contents should lactic 
acid be present. 

5. The Volatile Acids. These acids are best detected by their 
smell, their volatility, and their reaction. 

Butyric acid is recognized by the pungent odor of rancid butter 
given off when the stomach-contents are evaporated. It is recognized 
by the following reaction : To a small quantity of the liquid add a 
small quantity of alcohol and two drops of strong sulphuric acid ; 
heat for a short time ; a characteristic smell of butyric ether, like that 
of " pineapple ram," is given off. 

Butyric acid is also detected by Uffelmann's reagent. A few c.c. of 
the filtered gastric fluid are shaken with three or four times the amount 
of ether. The ether is poured off when it rises on the top, and fresh 
ether added and the washing repeated. After the third washing the 
ether that cannot be poured off is evaporated by means of a water- 
bath. Add a few drops of water to the residue and then an equal 
amount of the reagent. The characteristic color is produced. It 
strikes a tawny yellow color with a reddish tinge. As much as one 
part of the reagent in 2000 is required. 

In addition to Uffelmann's test the volatile acids may be detected 
by boiling a few c.c. in a test-tube, over the mouth of which blue lit- 
mus-paper is attached. If acid is present, its vapor will change the 
blue to red. Acetic acid is recognized by its odor, particularly after 
heating the solution. It may be detected as follows : Secure an 
ethereal extract of the gastric contents (as above), evaporate in a water- 
bath, and dissolve the residue in water. Neutralize the watery solu- 
tion with sodium carbonate, and then add neutral ferric chloride solu- 
tion. A blood-red color results if acetic acid is present. 

Alcohol is detected by its odor and by Lieben's iodoform-test. 
Distill the stomach-contents, add to a portion a small quantity of liquor 
potassae, and then a few drops of iodine-iodide of potassium solution. 
A precipitate of iodoform takes place slowly if alcohol is present. If 
acetone is present, it forms rapidly. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 789 

6. The Products of Digestion. The ultimate products of diges- 
tion are the proteoses and peptones. If they are present in the stomach- 
contents, it shows that hydrochloric acid and pepsin must have been 
secreted in the stomach. If vomiting occurs soon after food is taken, 
or if there is obstruction at the lower end of the oesophagus, these 
products are not present. Syntonin is a product of digestion which 
precedes the two above given. To ascertain if digestion has taken 
place, it is necessary only to test for syntonin and then employ the 
biuret test. Syntonin is detected by neutralizing the gastric contents 
with a solution of sodium hydrate. The precipitate is syntonin, which 
is soluble in an excess of alkali, and may be again precipitated by an 
alkali. After nitration and removal of the syntonin, proteoses and 
peptone are detected by the biuret test. 

7. Pepsin. If HC1 is present, add 5 c.c. of a gastric nitrate to a 
small piece of egg-albumin. Allow digestion to take place for several 
hours at 37° to 40° C. Non-digestion indicates absence of pepsin. 

If HC1 is absent, pepsinogen is found alone. Add two drops of a 
25 per cent. HC1 solution to 10 c.c. of the gastric contents. Add to 
this solution a small portion of egg-albumin. If it is dissolved, pep- 
sinogen was converted into pepsin by HC1. 

8. Rennin (the milk-curdling ferment). This may be detected as 
follows : From 5 to 10 c.c. of cow's milk of neutral reaction is boiled and 
added to neutralized and filtered gastric juice. Place the mixture on a 
warm bath heated to 30° or 40° C. The casein of the milk is precipi- 
tated in flakes in from twenty to thirty minutes if the ferment is present. 

9. The Carbohydrates. Add a few drops of Lugol's solution to 
the gastric contents. If starch is present, it turns blue. If erythrodex- 
trin, it becomes purple. If the digestion has proceeded so far as to 
change starch into dextrose, the iodine hue remains unchanged. The 
starches should be completely digested an hour after they are taken 
into the stomach, hence in health the iodine hue should not change after 
this time. 

III. The Digestive Power. Giinzburg has introduced the use 
of iodide of potassium in the following way : From three to five grains 
are placed in a rubber tube with extremely thin walls ; the ends of 
the tube are then bent and brought into apposition with each other 
and fastened in that position with three fibrin threads made firm by 
preservation in alcohol. The whole packet is then pressed into an 
empty gelatin capsule and given to a patient to swallow one-half hour 
after a test-breakfast. The saliva is tested for iodine every fifteen 
minutes. The more rapid the solution of the capsule and fibrin 
threads the sooner the iodine can be absorbed and appear in the 
saliva, and hence this rapidity is an index of the digestive energy. 

The method is liable to fallacies. Solution of the fibrin may take 
place in the intestine instead of the bowel, and the threads may be 
loosened by the acids of fermentation instead of by digestion. Never- 
theless, the test is a valuable one, especially when aspiration is inad- 
missible. 

The digestive power can be estimated by ascertaining (1) the pres- 
ence of gastric juice and (2) its activity. 



790 SPECIAL DIAGNOSIS. 

1. The Gastric Juice. Wash out the fasting stomach with 400 c.c. 
of lukewarm water ; test by litmus-paper for neutrality, then inject 
50 c. c. of a 3 per cent, solution of soda. Allow the solution to remain 
twelve minutes and then remove by washing out the stomach with 
400 c.c. of water. If the HC1 secretion is normal, the soda solution 
is neutralized. If it is deficient, the solution remains alkaline. The 
presence of pepsin is then to be determined. 

2. The Activity of the Gastric Juice. The white of one or two eggs 
should be boiled in four ounces of water and then administered. 
Remove the stomach-contents one-half hour later. The stomach should 
be emptied by lavage beforehand. The residue removed will show 
if digestion is complete, and proteoses and peptones may be tested for 
by the biuret reaction. 

Test for the Activity of the Gastric Juice and of the Movements by a 
Test-meal. Ewald's test-breakfast must be employed if the patient 
cannot bear more solid food, otherwise Leube's test-meal should be 
used. If digestion is normal, the stomach-contents removed from five 
to seven hours after a test-meal are neutral and contain a few flakes of 
mucus. At the end of five hours the stomach-contents are acid and 
contain peptone, some undigested muscle-fibres, and starch-grains. If 
the stomach contains undigested food at the end of seven hours, the 
contents are acid and contain peptones, indicating delay in digestion. 

IY. The Motor Power. Ewald and Sievers have suggested the 
use of salol ; fifteen grains are given, and normally salicylic acid 
should be detected in the urine in from forty to sixty minutes, or in 
seventy-five minutes at the latest. If it is deferred still longer, motor 
insufficiency is indicated. The sign is of value only when the excre- 
tion is delayed. Urine containing salicylic acid gives a dark, brown- 
ish-red color upon the addition of a drop of tincture of the chloride of 
iron. 

Klemperer's oil-test is more accurate, although disagreeable. One 
hundred grammes of oil are placed in the stomach by the stomach- 
tube. In two hours the stomach-contents are removed by aspirating, 
previously adding a little water. The amount of oil is dissolved by 
ether, the solution evaporated, and the residuum of oil weighed. Sev- 
enty-five to eighty per cent, of the oil should be discharged in two 
hours. 

V. The Absorptive Power. Penzoldt and Faber recommend the 
administration of three grains of chemically pure iodide of potassium 
— i. e., free from iodic acid — a short time before dinner. Any frag- 
ments of free iodine adhering to the iodide of potash are first carefully 
washed away. The saliva is tested for iodine with starch-paper and 
fuming nitric acid. If absorption is active, a violet color is obtained 
in from six and one-half to eleven minutes, and a blue color in from 
seven and one-half to fifteen minutes. Zweifel directs that 3 grains 
(0.2 gramme) of iodide of potassium be administered in a gelatin cap- 
sule, and 3 J oz. of water (100 c.c.) taken ; iodine is detected in about 
eight minutes in the saliva. The character of the food taken is said 
to have considerable influence in retarding the appearance of the reac- 
tion, so that the blue reaction may not appear for forty-five minutes. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 791 

Boas states that in dilatation of the stomach the reaction may be de- 
layed to two hoars, and in cancer as long as eighty-two minutes. 
Both motor and absorptive power are recognized also by digestive delay. 

Clinical Value of a Chemical Examination of the Vomitus or Stomach- 
contents. It cannot be gainsaid that the chemical examination of the 
stomach-contents is of the utmost clinical value. It is just as certain, 
however, that the results attained by such examination should not be 
final in the formation of a diagnosis ; that alone they do not meet the 
expectations of clinicians. This is particularly so when we attempt to 
deduce a scientific therapeusis from such examination. To rely upon 
the results of such examination alone would lead to failure. The diag- 
nosis, and, therefore, the rational therapeusis, must rest not alone upon 
a chemical examination, but also upon other methods of examination 
of stomach-contents, the physical examination of the stomach, the his- 
tory and progress of the case, and the subjective symptoms. In short, 
a general view must be taken, and all methods of inquiry employed. 

Diseases of the stomach require for their correct estimation broader 
lines of investigation than almost any other organ of the body. More- 
over, the practitioner must not be discouraged if he cannot employ 
chemical methods with the skill of the laboratory expert. The simple 
methods detailed above can be conducted by any educated physician. 
For practical purposes, it is only necessary to determine the total acid- 
ity, the presence of free acids, the presence of free HC1, the presence 
of lactic acid and of the volatile acids. 

Finally, the clinician must not be discouraged if the stomach- 
contents cannot be secured, on account of the contraindications pre- 
viously detailed. An approximate diagnosis — probably not so precise 
or final — can usually be made by means of a physical examination of 
the stomach and a consideration of the symptoms. 

The results of the chemical examination have the clinical value 
estimated herewith. In the first place, we find whether the acidity 
is increased or diminished. 

1. Diminished acidity, or anacidity, means deficiency in the amount 
of HC1 secreted. Diminished acidity may be due to functional or 
organic disease of the stomach. It occurs in fever, in chlorosis, and 
pernicious anaemia, chronic wasting diseases, including tuberculosis, 
and acute infectious diseases from functional disturbance of nervous or 
hsernic origin. It occurs in chronic dyspepsia from irregularities in 
diet. It is also deficient in congestion, acute catarrh or atrophy of the 
mucous membranes, and in carcinoma, which apparently modifies gas- 
tric secretion. 

2. Increased acidity may be due to an increase of hydrochloric acid 
— hyperacidity, or to an increase of the organic acids — increased acidity, 
a. Hypersecretion of HC1 takes place in the early stages of gastric 
irritation — dyspepsia. It may be increased in gastric ulcer, b. In- 
creased acidity (organic acids) may be due to excess of (1) lactic acid ; 
(2) of butyric acid, and (3) of acetic acid. Excess of lactic acid is due 
to fermentation of carbohydrates from the growth of the bacillus acidi 
lactici or bacillus lactis aerogenes ; of butyric acid, to butyric acid 
fermentation ; of acetic acid, to alcoholic fermentation of the above- 



792 SPECIAL DIAGNOSIS. 

mentioned class of foods. Alcoholic fermentation is often due to the sar- 
cina?. In short, these acids result from bacterial fermentation, a process 
which takes place only when there is delayed motor power, or when 
the normal antiseptic — the HC1 — is absent or diminished. Hence, we 
find these acids in weakness of the muscles, as in dilatation, in organic 
obstruction of the pylorus, and in cancer of the stomach ; while the 
bacteria are found on microscopical examination. 

3. Free hydrochloric acid is diminished in acute and chronic catarrh 
of the stomach (gastritis), in chronic dyspepsia, in ulcer of the stomach 
and duodenum, in gastric atrophy, in dilatation, in gastric carcinoma 
(early stage), and from all general causes which lessen the total acid- 
ity, including diabetes and Addison's disease. Of course, deficiency 
of hydrochloric acid means deficiency of functional activity, and goes 
hand-in-hand with diminished motor and absorptive power. The acid 
is increased in the early stages of irritative dyspepsia and in ulcer of 
the stomach, and at different periods in the gastric neuroses. The 
most common causes of increase of HC1 are the gastric neuroses. 
Hydrochloric acid is absent entirely in advanced chronic gastritis and 
in the gastric neuroses. In the former there are evidences of fermen- 
tation. HC1 is often absent in cancer, but unless constantly absent, 
and two or more other facts of value can be secured, the diagnosis 
cannot be made on the chemical examination alone. 

4. Lactic acid. Its presence points to fermentation, hence it is asso- 
ciated with lesions that are accompanied by bacterial fermentation. 

It is present in carcinoma, as pointed out by Boas. Fermentation 
is not the only condition in which it occurs. It is nearly always found 
after a meal of meat, and is known as sarcolactic acid. It may occur in 
chronic catarrhal gastritis. In cancer of the stomach lactic acid is the 
most common objective sign. Its absence does not exclude carcinoma. 
It may be detected before a tumor is palpable. Therefore, if lactic 
acid is present and free HC1 absent, cancer can be pretty safely diag- 
nosticated, particularly if stagnation of stomach-contents is also pres- 
ent. Boas recommends a meal which will not yield sarcolactic acid. 
It consists of one to two litres of oatmeal gruel, to which a little salt 
may be added. It should be removed by expression one hour after it 
has been taken. It is well to remove all food by lavage six hours 
before the test-meal is given. 

The clinical value of the remaining chemical tests and investigations 
need not be explained. They indicate inability of the gastric function 
to accomplish digestion, but do not point to any special gastric affec- 
tion. They are of value in distinguishing between gastric neuroses and 
an organic disease. In both there are pronounced gastric symptoms ; 
if the examination shows normal digestive powers, a neurosis is indi- 
cated. 

Gastkic Hemorrhage. Hemorrhage of the stomach, hwmateme- 
sis, or vomiting of blood, is due to an organic lesion, or the effects of 
acute irritant poisoning. The blood is vomited. Care must be taken 
to see that the blood is not from the upper air-passages, and previously 
swallowed. If hemorrhage is profuse, the blood may cause irritation 
of the larynx, and provoke paroxysms of coughing. It is often cliffi- 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 793 

cult, therefore, to distinguish between hemorrhage from the lungs and 
hemorrhage from the stomach. 

HiEMATEMESIS. HAEMOPTYSIS. 

1. Previous history points to gastric, j 1. Cough or signs of some pulmonary- 
hepatic, or splenic disease. 



2. The blood is brought up by vomiting, 
prior to which the patient may experience 
a feeling of giddiness or faintness. 



with particles of food, and has an acid re 
action. It may be dark, grumous, and 
fluid. 

4. Subsequent to the attack the patient 
passes tarry stools, and signs of disease of 
the abdominal viscera may be detected. 



or cardiac disease precedes, in many cases, 
the hemorrhage. 

2. The blood is coughed up, and is usu- 
ally preceded by a sensation of tickling in 
the throat. If vomiting occurs, it follows 
the coughing. 
3. The blood is usually clotted, mixed i 3. The blood is frothy, bright red in 

color, alkaline in reaction. If clotted, it is 
rarely in such large coagula, and muco- 
pus may be mixed with it. 

4. The cough persists, physical signs of 
local disease in the chest may usually be 
detected, and the sputa may be blood- 
| stained for many days. ( Osler. ) 

The hemorrhage may continue within the stomach without exciting 
vomiting. The general symptoms of hemorrhage may appear, first, as 
pallor, dimness of vision, giddiness, or faintness. The blood which 
comes from the stomach is usually acted upon by the gastric juice, and 
is dark, clotted, and partly digested. It is often mixed with food. 
Its reaction is acid. In large hemorrhages the blood may be fluid 
and of a scarlet color ; but if retained for any length of time, it is 
coagulated. The vomited matter has the appearance of coffee-grounds, 
when there is a small amount of blood. When large in amount and 
digested, it appears like tar. 

Vomiting is usually followed by movements of the bowels. The 
matter discharged is of characteristic appearance. It is black or tarry. 
It is distinguished from hemorrhage of the intestinal canal below the 
duodenum by the color of the blood. In intestinal hemorrhage the 
blood is dark red, and not necessarily tarry. The dark stools must not 
be confounded with the same character of stools seen when iron or 
bismuth is taken. In rare instances a hemorrhage into the stomach 
may take place from disease of the lower part of the oesophagus. 

Causes. 1. General diseases, from changes in the blood, cause gas- 
tric hemorrhage, as scurvy, purpura, hemorrhagic smallpox, yellow 
fever, acute yellow atrophy of the liver, and severe anaemia, leukaemia, 
Hodgkin's disease, and pernicious anaemia. 2. Ulcer of the stomach. 
3. Cancer of the stomach. 4. Ulcer of the duodenum. 5. Portal 
congestion, as in cirrhosis of the liver, and other forms of chronic 
hepatic disease. 6. Disease of the spleen. 7. Congestion due to dis- 
ease of the heart. 8. In chronic Bright\s disease with atheroma. 9. 
Rupture in aneurism. 10. Vicarious menstruation. 11. Cohen asserts 
that it occurs in vasomotor ataxia. 

Profuse and sudden hemorrhage, in the absence of well-marked 
symptoms of disease, is in nearly all cases due, either to latent ulcer, 
or to congestion of the stomach from early cirrhosis of the liver. 

General Examination. The objective examination has thus far 
been confined to a study of the stomach. The student will infer from 
the previous chapters that in order that on the one hand the possible 



794 SPECIAL DIAGNOSIS. 

cause of the gastric disorder may be determined, or, on the other, the 
effect of gastric disorder upon the other organs ascertained, they must 
be examined carefully. Moreover, valuable data in the recognition of 
gastric affections and the diagnosis of the various forms are secured by 
such examination. The general appearance of the patient, the state of 
nutrition, and the degree of strength furnish suggestive facts in the 
diagnosis. As well said by Stockton : 

" The preoccupied and dejected manner observed in those suffering 
from continued gastric flatulency ; the restless, discomposed behavior, 
the stooped posture and half-surprised expression often seen in the 
victims of gastralgia ; the emaciated, weak, and cachectic appearance 
frequently accompanying chronic food stagnation, are good examples 
of the value of the general appearance in the diagnosis." 

It must be remembered that any local source of irritation distant 
from the stomach, as the eyes, the nose and pharynx, the uterus and 
ovaries, and the rectum, may be the primary cause of gastric disorder. 
The study of the hepatic and intestiual functions assist in the diag- 
nosis. Examination of the urine and the blood may enable us to 
determine the nature of a gastric morbid process. Even the study of 
the skin is of importance. 

" A sallow, earthy-colored skin, showing improper secretion ; a dry, 
harsh skin, with too rapid loss of epithelium, showing poor nutrition ; 
a skin showing oedema, poor capillary circulation, lividity, or acne ; 
certain forms of eczema, excess of pigment, or syphilides may afford 
important information as to the digestion, inasmuch as some of these 
may be the results and others accompaniments of gastric disturbance " 
(Stockton). 

The Blood. Examination of the blood enables us to determine 
the degree of anaemia which may be the cause of digestive failure. 
The examination must be exhaustive. If a leucocytosis is present, the 
gastric neuroses may be excluded. In carcinoma there is not only a 
severe secondary ansemia, but also poikilocytosis and a multinuclear 
leucocytosis. Such changes are without doubt the result of interference 
with the digestion because of motor inactivity. Moreover, certain 
gastric diseases have specific effects upon the blood. Gastric ulcer 
may be distinguished from gastric carcinoma, by the fact that digestive 
leucocytosis occurs in the former while it is absent in the latter. 

The Urine. No study of a gastric disorder is complete without 
an exhaustive examination of the urine. For diagnostic, but chiefly 
for therapeutic purposes, the presence of renal insufficiency, hyper- 
lithuria, indicanuria, glycosuria, peptonuria, and albuminuria must be 
tested for. 

The Reaction. The reaction of the urine is modified by the state of 
the stomach. In health the urine is alkaline after a full meal of ordi- 
nary character. When HC1 is absent from gastric contents, this normal 
alkalinity does not occur. Alkalinity is rarely seen in gastric carci- 
noma. 

The Chlorides. The chlorides are lessened when a small amount of 
food is taken ; a similar cause lessens the amount of urea. Both are 
decreased in carcinoma and in benign diseases of the stomach. But 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 795 

the chlorides are diminished in carcinoma without a proportionate 
lessening of the urea. It is this disproportion which is of diagnostic 
value, as pointed out by Nothnagel, in carcinoma ventriculi. 



Diseases of the Stomach Characterized by Fever, with Pain and 

Vomiting. 

Acute Gastritis. The simple variety of acute gastritis varies 
according to the cause, from a slight attack of vomiting after indiscre- 
tion in diet, Avith ordinary symptoms of indigestion, to the more severe 
forms ushered in by chill and attended with fever. 

In the mild forms there is a sense of fulness and discomfort in the 
epigastrium, attended with nausea. The appetite is lost, and there 
may be disgust for food, and the flow of saliva is increased. There is 
undue acidity. On examination the epigastrium is found to be tender. 
The onset of the attack is attended with giddiness, flashes of light 
before the eyes, frontal headache, and some prostration. The pulse is 
increased in frequency. When this nausea is most pronounced the 
face is pale and the extremities cold. Vomiting then occurs, the 
matter ejected consisting of ingesta only slightly changed, with mucus 
and watery fluid. It is very bitter. It is often colored green from 
bile-pigment. Another attack of vomiting may be sufficient to give 
relief, or it may be repeated for twenty-four to forty-eight hours every 
hour or two. After the stomach is relieved of food, mucus and bile 
alone are vomited. 

Examination of Stomach-contents. The reaction of the vomited 
matter is neutral or faintly acid. No free hydrochloric acid is present, 
but later lactic and fatty acids are found. Pepsin is diminished in 
quantity. 

Twelve to twenty-four hours after the gastric symptoms intestinal 
symptoms may arise. Borborygmi and colicky pains are complained 
of, followed by diarrhoea, with some tenesmus. 

Herpes labialis may occur, and some writers speak of a peculiar 
odor which is exhaled from the skin. The more severe cases are 
ushered in with chill followed by fever. The local symptoms are 
much aggravated. The tongue is furred, and the breath foul. The 
vomiting is frequent and severe. The skin is livid and the pulse be- 
comes rapid. 

Diagnosis. In the acute cases attended by fever it may be mistaken 
for meningitis, peritonitis, or hepatitis. The same gastric symptoms 
may usher in an attack of pneumonia. The possibilities of a mistake 
are to be borne in mind, and in all cases of vomiting with fever due 
regard must be paid to the possibility of the gastric symptoms being 
symptomatic only. It must be borne in mind that the same group 
of symptoms that belong to gastritis accompanies the exanthematous 
diseases, and diphtheria, dysentery, pyaemia, and puerperal fever. 
They may be of reflex origin, or due to the action of fever, poison, or 
ptomaines on the stomach. Ewald calls it sympathetic gastritis when 
the symptoms are the same as in the simple variety, masked, however, 



796 SPECIAL DIAGNOSIS. 

by the primary disease. Sometimes, however, as in the eruptive 
fevers, attention is directed to the state of the stomach, to the exclusion 
of other conditions. And often, to the surprise of the student, an erup- 
tion or inflammation ensues, which indicates the true nature of the case. 

In cases of gastritis, therefore, endeavor to find a local cause for the 
symptoms. If there is no history of indiscretions in diet, of exposure, 
of exhaustion, or mental shock, on account of which digestion might 
be arrested, then inquire for a history of exposure to contagious dis- 
eases and look for the earlier evidences of exanthemata. If the result 
of the examination is still unsatisfactory, examine the condition of 
each individual organ, particularly bearing in mind meningitis, pneu- 
monia, peritonitis, nephritis, and general infections. 

Mycotic and diphtheritic gastritis occur secondarily to typhoid fever, 
pneumonia, pysemia, smallpox, and sometimes diphtheria. The mucous 
membrane may be covered with patches in areas or throughout its 
whole extent. 

Some special micro-organisms irritate the gastric mucosa, as the 
anthrax bacillus and the sarcinse and yeast fungi in cancer and dilata- 
tion of the stomach. Rarely tuberculous inflammation with ulceration 
takes place, and other micro-organisms have been described. Klebs 
found the bacillus gastricus with numerous spores in the tubules, as 
a consequence of which a gastritis was set up. 

The mucous membrane itself escapes infection from micro-organisms, 
because of the character of its secretion. The acid gastric juice is 
antagonistic to and causes the death of micro-organisms. Tuberculo- 
sis, for instance, rarely attacks the stomach for this reason. 

Phlegmonous Gastritis. This is a very rare affection, in which 
the inflammation is seated in the submucosa and leads to perforation. 
The onset is sudden. The chief local symptom is intense pain in the 
epigastrium, with a burning sensation. There are great acidity, dry 
tongue, and absolute anorexia. The fever is high and characterized 
by delirium. Chills usually accompany it. The pulse is small, rapid, 
and irregular. The matters vomited are first mucus, then pus. The 
patient is extremely restless and anxious, even delirious, and early 
passes into coma. Death takes place from collapse. It is impossible 
to make an absolute diagnosis, as local peritonitis and abscess of the 
liver are characterized by the same symptoms. In abscess a tumor 
may form in the epigastrium. It may occur idiopathically, but it fre- 
quently occurs in septicaemia, and follows trauma. 

Toxic Gastritis. This form of gastritis is allied to the former in 
the severity of general symptoms. It is the result of the swallowing of 
irritating poisons, of which phosphorus, arsenic, bichloride of mercury, 
and caustic acids and alkalies are the most common. It is attended by 
inflammation of the mouth, oesophagus, and stomach. There are sali- 
vation and dysphagia, and constant vomiting of blood, often with shreds 
of mucous membrane. The patient is restless, and may have convul- 
sions ; collapse readily develops. In mild cases, in which the local 
effects of the corrosive substance have been mitigated by proper anti- 
dotes, sloughs occur, leaving behind ulcers on the mucous membrane, 
which, after healing, result in deformity or stenosis of the oesophagus. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 797 

Some cases are attended by other symptoms peculiar to the special 
poison. Thus with arsenic there are choleraic symptoms ; in phos- 
phorus-poisoning the symptoms come on late after its ingestion, and 
are attended by jaundice and symptoms of acute yellow atrophy. 

Diseases of the Stomach Characterized by Indigestion. 

Functional Disorders of the Stomach. The Neuroses. Func- 
tional disturbances of the stomach are due to impairment of the motor 
power of the stomach, impairment of the secretory function and of the 
sensory function. The following table of Ewald, as given by that 
distinguished authority, is a classification of the various neuroses mid- 
way between the symptomatic and the etiological : 

The Neuroses of the Stomach. 

1. Conditions of Irritation. 

a. Sensory. b. Secretory. c. Motor. 

Hyperesthesia. Hyperacidity. Eructation. 

Nausea. Hypersecretion. Pyrosis. 

Hyperorexia. Vomiting. 

Anorexia ex hyperesthesia. Colic. 

Parorexia. Tormina ventriculi. 
Gastralgia. 

2. Conditions of Depression. 

Polyphagia. Anacidity. Atony. 

Anaesthesia. Insufficiency of the pylorus and 

cardia. 
3. Mixed Form. 
Gastro -intestinal neurasthenia (dyspepsia nervosa). 
4. Eeflexes from Other Organs upon the Gastric Nerves 

Reflexes from the brain, eyes, spinal cord, kidneys, liver, sexual organs, and 
intestines manifest themselves in the forms mentioned in 1 and 2. 

It must not be supposed that each of the above-named symptoms 
occur in an individual, or that functional disturbances may be limited 
to alterations of the sensory and secretory or the motor apparatus, re- 
spectively. They do not occur, as Ewald states, as distinct indepen- 
dent' diseases, but usually in groups, " either appearing simultaneously 
or closely following one another during the course of the malady, pass- 
ing before us like an ever-changing scene." They may arise directly 
from disease of the stomach, or reflexly from disease of other organs, 
as the brain, the spinal cord, uterus, kidneys, liver, eyes, and nose. 

Etiology. Gastric neuroses are of most frequent occurrence in 
women, especially during the years from puberty to the menopause. 
The accidents of childbirth are predisposing factors. In both sexes 
they are of most frequent occurrence after the age of twenty years, 
because individuals are subjected to causes which lead to neuroses at 
this period of life. The gastric neuroses occur in all conditions of 
patients. They are more likely to occur in those who are poorly nourished 
or anaemic ; although persons who are distinctly robust may also suffer. 
While more common in the residents of cities, they may occur in 
farmers and others accustomed to an open-air life. Although we are 



798 SPECIAL DIAGNOSIS. 

oftenest called upon to treat them among the better classes, neverthe- 
less a large number of cases are seen among the poor. To analyze 
more closely the predisposing causes, we have to study individually 
all conditions and circumstances in life which lead to wear and tear, 
as in business or social affairs. The causes which Beard and others 
have forcibly pointed out as factors in the production of neurasthenia 
are especially prevalent in this country. 

In men, excessive devotion to business, or dissipation ; in women, 
excesses in social life, or the restraint of home cares, with, unhappily, 
too often, the irritation of marital relations, are the predisposing 
factors which lead to the development of this class of cases. Often 
patients in the large cities are subject to the neuroses in the spring 
after the dissipations of the winter. Behind this excess there is, no 
doubt, in the majority of cases, a nervous temperament that is respon- 
sible for the bringing out of the symptoms, particularly if, combined 
with this temperament, the patients live in an unhygienic way in 
regard to exercise, ventilation of their dwelling-places, and drainage, 
combined with improper diet. 

Symptoms. With the gastric neuroses other symptoms of neurasthe- 
nia are present, and the patient may seek advice for these symptoms, 
such as headaches of various kinds, changes in the mental condition, 
vertigo, insomnia, neuralgias, and all forms of paresthesia. Intimately 
connected with the neurasthenic state is that of hysteria, and therefore 
in gastric neuroses hysterical manifestations are most common. It may 
be impossible completely to define the border-line between neurasthe- 
nia and hysteria, and the gastric symptoms of the former are the gas- 
tric symptoms of the latter. While, therefore, general neurasthenic 
symptoms are prominent, in order to reach a diagnosis upon which 
proper lines of treatment can be based, the condition of the individual 
must be viewed as a whole, and no one symptom or group of symptoms 
exaggerated in our minds. 

Varieties. Ewald has divided the neuroses into those which arise 
from (a) irritation, those which arise from (b) depression, and (c) those 
in which both are combined — mixed neuroses. 

(a) 1. Sensory Neuroses of Irritation. HYPEKiESTHEsiA. The 
first result of irritation is hyperesthesia of the stomach, which is indi- 
cated by a feeling of fidness and tension, and of nausea. The sensation 
is allied to the normal, and is also seen in chronic gastritis, as well as 
in hysteria, meningeal irritation, cerebral tumors, and other diseases 
of the nervous system. The increased irritability is such that the 
gentlest irritant excites discomfort or a painful sensation. There is a 
continuous sensation of heat or cold, of gnawing, or pulling, or burning 
in the organ. The local sensation reflexly influences the physical life 
of the patient, so that hypochondriasis in some form attends it. The 
sensations may be relieved by food, to become worse if the stomach is 
emptied, although in the larger number of cases the trouble is aggra- 
vated during digestion. The sensations are likely to be aggravated by 
fasting a longer period than usual, or by restriction of the diet. Ex- 
cesses may aggravate them, and, on the other hand, they are said to 
follow debilitating states. Some foods, such as shell-fish, crabs and 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 799 

lobsters, or oysters, and strawberries, are likely to increase the peculiar 
sensations in the epigastrium, exciting mild depression, or burning, or 
even nausea. The excitation from these foods is usually due to pecu- 
liar idiosyncrasies of the individual. On account of the same idiosyn- 
crasies, pruritus, erythema, and urticaria occur, with headache and 
some fever. 

Deviations from the Sense of Hunger. Hyperorexia. 
When hunger is exaggerated it is known as boulimia, or hyperorexia. 
It may be temporary or permanent. When permanent it is obstinate, 
weakening, and exceedingly unpleasant. It may occur alone or be a 
symptom of various diseases of the nervous system, as manifest disease 
of the brain, neurasthenia, hysteria, and psychoses. It complicates 
such disorders as diabetes, and may be of temporary duration in con- 
valescence from acute disease. The disorder accompanies migraine, or 
hypochondriasis, and exophthalmic goitre. Analogous to it is perver- 
sion of the appetite, as seen in pregnancy, in children, and in mental 
disorders. 

Anorexia. Loss of appetite, or repugnance to food. In the first 
instance, there is simply loss of appetite ; in the second, there is repug- 
nance toward food, or nausea at the sight of it. Loss of appetite 
accompanies dyspepsia in all forms. In the gastric neuroses it occurs 
spontaneously, or is due to hyperesthesia of the stomach, and therefore 
may arise from central or peripheral conditions of irritation. It is 
commonly seen following central nerve perturbation. The patient is 
hungry, and sits down to the meal fully prepared to satisfy himself. 
The first mouthful is at once followed by anorexia, which may almost 
amount to nausea. On account of these symptoms the patient eats less 
and less of solid food, which soon results in disturbance of nutrition 
affecting the higher centres. On the other hand, profound mental dis- 
turbance may be an exciting cause, so that after the death of a friend, 
or shock of any kind, the patient is unable to take food. Loss of appe- 
tite may be the only manifestation of the gastric neurosis, but because 
nutrition is so seriously interfered with, it soon results in other local 
or general symptoms. Fen wick points out that its relationship to ema- 
ciation and enfeeblement is such that grave organic diseases may be 
simulated. Thus it may be mistaken for phthisis, and a general ex- 
amination alone is sufficient to distinguish it. 

Gastralgia. Pain in the stomach occurs in organic disease, as in 
ulcer or cancer, or forms of gastritis. It also attends a gastric neurosis, 
and may be the only symptom of this neurasthenic state. Such pain 
is functional, and is found in anaemic, neurotic women. It may, how- 
ever, occur in all classes. It is characterized by sudden pain in the 
epigastrium, usually without regularity, though at times it may be dis- 
tinctly periodic. There may not be any definite relationship between 
the attack of pain and the taking of food, though it is most apt to 
occur when the stomach is empty. Some kinds of food may aggravate 
it, though, in general, eating relieves the pain. If the epigastrium is 
examined, it will be found to be free from tenderness, and indeed 
pressure with the palm of the hand may give relief. The pain is of 
an agonizing character, sometimes sharply localized, or again diffuse. 



800 SPECIAL DIAGNOSIS. 

It may even resemble the girdle-sensation. On account of the severity 
of the pain the patient may be compelled to double himself up to relax 
the abdominal muscles. The breath is short, and speaking is done in 
a whisper. The attack is attended by more or less collapse, and the 
patient may complain of the sensation of impending death. There is 
pallor of the face, which is distorted with pain, and the brow is covered 
with perspiration. The pain may radiate along the spinal nerves in 
close situation to the stomach, and there is often vigorous pulsation of 
the abdominal aorta. 

The attack may last but a few minutes or continue for hours. It 
sometimes terminates suddenly with vomiting, or is relieved as soon 
as food is taken. After the attack the patient is exhausted and re- 
laxed, and passes an abundance of urine of low specific gravity. 

The gastralgias that are due to disease of the central nervous system 
are often most puzzling. Rosenthal has written exhaustively on this 
subject. Types of gastralgia of this character are seen in the gastric 
crises of tabes, first described by Charcot. Recent observers have 
found that it is due to sclerotic degeneration of the vagus nucleus. 
The patient is suddenly seized with severe pains, which may begin in 
the groin and ascend along both sides of the abdomen to the epigas- 
trium, to which point they are fixed. Pain in the shoulders occurs at 
the same time. The pains are characteristic of lumbar ataxia in their 
lightning-like rapidity. With the pain the heart's action is increased 
in rapidity and force. There is no rise in temperature. At the same 
time there is uninterrupted and painful vomiting, which is attended by 
nausea and vertigo. The gastric pain may continue uninterruptedly 
for two or three days. It belongs to the pre-ataxic period, so-called, 
but is almost sure to continue throughout the whole course of the dis- 
ease. The nature of the stomach-contents bears no relation to the 
pain. The frequency of the attacks is variable. They may recur at long 
periods, or as frequently as once a month or once a week. Another 
special characteristic is the sudden relief that is given without cause. 

Neurasthenic Gastralgia. Neurasthenic gastralgia occurs in 
patients who are suffering from neurasthenia, and is divided by Rosen- 
thal into two forms, the one irritative, the other depressant ; these are 
related by transitional forms. The early symptoms of neurasthenia 
(q. v.), particularly in the irritative form, with painful points in the 
nape of the neck and between the scapulae, or often lower down on the 
vertebrae, with neuralgias and paresthesia in the upper and lower ex- 
tremities, are attended by periodical gastralgia. The gastralgia is 
characterized by a boring sensation which, during the attack, radiates 
over the lower ribs to the median line. It is accompanied by vaso- 
motor symptoms and symptoms of cerebral anaemia. In the depressant 
form the patient complains of weight and fulness, or a dragging sensa- 
tion after eating, which is constant instead of paroxysmal. The neu- 
ralgic pains are not so marked, motor exhaustion is not so prominent, 
and the pain in the back is not so intense as in other varieties. In 
both instances on deep pressure over the region of the nerve-plexuses 
which follow the bloodvessels in the abdomen, there is sharp and un- 
pleasant pain radiating to the epigastrium. Burkart considers these 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 801 

painful points to be present in all cases, while Bichter believes that 
pressure over the stomach and abdomen is not painful. With such 
pain there is usually increased pulsation of the abdominal aorta, partic- 
ularly during the time of the paroxysm. In neurasthenic gastralgias 
there is increased sensitiveness to the electrical current and increased 
irritability of the sensory nerves of the trunk, which may also be ex- 
tended to the limbs. 

Neurasthenic gastralgia must be distinguished from the gastralgia 
of organic disease and the gastralgia of hysteria. The gastralgia of 
organic disease is recognized by observing the condition of the stomach 
when fasting and by studying the secretion. In organic disease there 
is retarded digestion ; in gastric neuroses digestion is completed in the 
normal limit of time — seven hours. Hysterical gastralgias are recog- 
nized by the presence of the usual symptoms of hysteria, in which the 
psychical factors occupy a prominent place, associated with convul- 
sions, paralyses, pupillary inequalities, hemianesthesia, and electrical 
sensibility. Most characteristic, however, is the alternation of hysteri- 
cal gastralgias with neuralgia, or neuroses in other organs. 

(a) 2. Secretory Neuroses of Irritation. Hyperacidity and 
Hypersecretion. Hyperacidity is the increase of the normal 
amount of hydrochloric acid secreted, due to a neurosis of the secretory 
function. Hyperacidity begins when the amount of acid in the fluid 
withdrawn from the stomach in the usual way is between 60 and 70 
per cent. It must not be forgotten that it is a symptom of gastric 
ulcer, but it exists as a neurosis independent of any organic lesion of 
the stomach. It has been observed in nervous diseases, as hysteria 
and melancholia, and as a reflex symptom in gallstones and renal 
calculus. 

Hypersecretion occurs in two forms, the periodical and constant. 
The acid is not necessarily increased. The periodical occurs after eat- 
ing ; it has no direct connection with food. It is seen in neurasthenia 
and locomotor ataxia. In chronic hypersecretion the gastric juice, 
which is usually hyperacid, is in excess, so that the fasting stomach 
may contain large quantities, even to a pint and a half, without food 
and only slightly tinged by bile. In chronic hypersecretion the diges- 
tion of starches is delayed, but that of albuminoids is very prompt. 
After an abundant meal consisting of meat and starches the meat dis- 
appears entirely. Hypersecretion occurs in about half of all the stom- 
ach disorders, according to Riegel. It is more common in men than 
in women. The acid fluid causes the hypersesthetic conditions in the 
gastric region previously described. Pain and eructation, heartburn 
or gastralgia, vomiting of sour masses, occur with the digestive dis- 
turbances of chronic gastritis. The tongue is usually clean and the 
appetite increased rather than diminished. As a result, atony of the 
muscular coat takes place, followed by gastrectasia. The neurosis is 
then converted into an organic lesion, and the symptoms of dilatation 
arise. 

Reichman's disease is a hypersecretion of the gastric juice, and there 
are two forms — the acute, which is generally of nervous origin, and 
the chronic. The latter is seen in emaciated persons ; the stomach is 

51 



802 SPECIAL DIAGNOSIS. 

dilated, and succussion-splash is readily obtained. The diagnosis is 
made in part by examination of the gastric contents, which are re- 
moved five to six hours after the meal. The quantity will be found 
large. On standing, the material becomes separated into three layers 
— an upper, frothy layer ; a middle, turbid, yellowish layer, and a 
lower, consisting of starchy matter. In order to determine that hyper- 
secretion exists, the stomach-contents are removed in the evening, and 
the viscus washed out thoroughly until the water is no longer acid in 
reaction. The patient receives no food until the next morning, when, 
after the proper interval, the contents of the stomach are again evacu- 
ated. From 30 to 600 c.c. (1 to 19 ounces) of fluid will now be 
obtained, which, on examination, proves to be active gastric juice. 
The disease is chronic. 

In order to make a diagnosis the secretions must be secured while 
fasting. The patients usually improve on albuminous food, which 
differentiates it from gastralgia and pyrosis of acid fermentation. 
Alkalies give temporary relief. 

Gastroxynsis is a gastric neurosis in which, after mental overexertion 
or profound emotional disturbance, there is sudden vomiting of acid 
fluid, continuing for a considerable time. It is closely allied to 
migraine. 

(«■) 3. Motor Neuroses of Irritation. Eructations. Eructations 
and belching are phenomena of the gastric neuroses of motor origin. 
They usually occur in hysterical subjects rather than in neurasthenics. 
In the latter they are associated with other sensations, particularly op- 
pression and tension in the epigastrium. In hysteria they occur alone. 
There is increase in the contractility of the stomach, the pyloric 
sphincter contracts powerfully, and the stomach is distended ; gas is 
expelled at the cardiac end of the stomach. They may be due to 
paralysis of the cardiac end of the stomach rather than to contraction 
of the pyloric end. They occur involuntarily generally. They must 
not be confounded with the pseudohysterical vomiting which Bristowe 
has described. In the latter instance the gas is raised from the oesoph- 
agus by contraction of the muscles of the neck. Hysterical eructation 
is very frequently of oesophageal origin. The belching is loud and 
may occur in paroxysms. The gas is odorless, and hence is distin- 
guished from the gas of dyspepsia and fermentation ; it is hi all proba- 
bility the result of the swallowing of air. 

Pyrosis. Pyrosis, or heartburn, is the raising of sour masses from 
the stomach. The stomach-contents are not necessarily hyperacid. 
If acid, as in the normal gastric juice, or hyperacid, the regurgitation 
causes severe acrid and burning sensations. It is probably due to 
heightened contractility of the muscular coat of the stomach with 
pyloric contraction, which overcomes the weaker cardia. 

Pneumatosis. Excess of gas in the stomach. When the stomach 
is overdistended the diaphragm is pushed up, pressing on the heart. 
The patients are seized with severe dyspnoea. At first inspiration is 
difficult, and finally both inspiration and expiration become difficult. 
Palpitation of the heart and pulsation of the peripheral arteries take 
place. There is fulness of the head and a sensation of impending 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 803 

death. The patient may become unconscious. Relief can only be 
afforded by belching, when the attack rapidly subsides. Introducing 
a stomach tube gives immediate relief. 

Nervous Vomiting. (See Subjective Symptoms and Gastroxyn- 
sis). 

Tormina Yentriculi. Peristaltic Unrest. Characterized by 
borborygmi and gurgling, which begin immediately after eating, are 
heard at a considerable distance, and are a source of great annoyance. 
It is a common symptom of the gastric neuroses. 

Rumination (Merycismus). Rumination is a rare condition in 
which the patients regurgitate and chew the cud like ruminants. 

(b) 1. Secretory Neuroses of Depression. An acidity. An- 
aciclity of the gastric juice as a neurosis is found in hysterical persons 
and in neurasthenics. (See chemical examination Absence of Hydro- 
chloric Acid). 

(b) 2. Sensory Neuroses of Depression. Anaesthesia. In con- 
ditions of depression polyphagia, or the want of a feeling of satiation 
occurs ; if gluttony is excluded, it is a morbid condition of extreme 
rarity. 

(b) 3. Motor Neuroses of Depression. Atony, or Atonic Dys- 
pepsia. It accompanies gastritis ; it also occurs as a primary neurosis. 
The innervation of the nerve-centres regulating peristalsis is disor- 
dered. The primary disorder may be local or central. The movement 
of the chyme is tardy or insufficient. Atony should be applied to the 
disease of the motor function only ; or, as Rosenbach states it, to insuf- 
ficiency of the stomach. The symptoms develop gradually. At first 
oppression during digestion occurs, with swelling and fulness of the 
stomach. 

There is mental and physical torpor during the time of the digestive 
act. The symptoms become aggravated, and eructations occur, vomit- 
ing begins, and gradually the fermentative symptoms become most 
pronounced. At this period it is putrid, or fermentative dyspepsia. 
By the usual tests the motor power of the stomach is found to be 
diminished. The secretions are also scanty. 

Relaxation at Orifices. Relaxation of the Cardiac and Pyloric 
Ends of the Stomach from Conditions Besembling Paralysis. When 
the cardiac end is relaxed eructations and regurgitations occur. If 
large quantities of the material from the stomach are regurgitated and 
expectorated, the condition is pathological. It may lead to serious 
changes in nutrition. It may exist for years without bad results. It 
must not be confounded with the regurgitation from diverticula of the 
oesophagus. In the latter regurgitation is produced at will. 

(c) Mixed Neuroses. Nervous Dyspepsia. According to Ewald, 
this is the true gastric neurasthenia, which combines all forms of gas- 
tric neuroses. The clinical picture is made up of a combination of 
various neurosal symptoms. Leube considers nervous dyspepsia a 
group of symptoms of a cerebral nature due to abnormal irritability 
of the sensory nerves of the stomach during the normal digestive 
processes, the symptoms of which are hyperesthesia and nausea, hy- 
perorexia, anorexia, parorexia, and gastralgia. He thinks the true 



804 SPECIAL DIAGNOSIS. 

peptic activity of the stomach is unchanged. Although the anatomical 
or physiological explanation of the condition is difficult, the clinical 
symptoms are those of irritation of paralysis, the manifestations of 
which are intermingled, sometimes one and sometimes the other being 
most prominent. (See table, page 797.) 

The one characteristic feature is that the symptoms are mild. With 
severe forms of gastralgia nervous vomiting and boulimia do not occur. 
Symptoms of intestinal indigestion are usually associated in a mild 
degree. Constipation is of the most common occurrence, although in 
some cases there is diarrhoea. In other cases the intestinal indigestion 
is much aggravated, with mild gastric disturbances and anorexia, repug- 
nance toward taking food, furred tongue and mild nausea, constipation 
and colicky pain, either diffuse or in separate painful spots. The 
abdomen is distended and tympanitic, sometimes to a marked degree. 
It is called flatulent dyspepsia. Along with the gastric and intestinal 
symptoms, the general nervous symptoms to which the term neuras- 
thenia is applied are present. These nervous manifestations sometimes 
precede the local gastric symptoms, but as the latter develop the former 
become more aggravated. The dyspeptic conditions, as Ewald puts 
it, are on a neurotic basis, or are such as may occur in the form of reflex 
neuroses in chlorosis, menstrual disorders, uterine and ovarian disease, 
and intense physical or psychical excitement. As far as we know there 
are no great alterations in the chemical functions when anatomical and 
pathological changes are absent. An indigestion of short duration, a 
mild catarrh, recurring hyperemia, have been the primary cause of 
nervous symptoms in the digestive organs. 

Diagnosis. There are no characteristic symptoms, and the student 
must bear in mind that it may be necessary to make several examina- 
tions and listen to the story of the subjective symptoms frequently 
before a conclusion can be arrived at. This is all the more necessary 
because of the frequency in which organic lesions and neurasthenic con- 
ditions are present at the same time. The course of the disease must 
be observed for a long time, all possible causal factors investigated, and 
all the general signs of neurasthenia carefully considered. In addition, 
it may be necessary to use therapeutic tests. If the possible organic 
diseases are not relieved by such measures, there must be a deeper basis 
for the gastric symptoms. Just as in neurasthenia and in neurasthenic 
states elsewhere, the peculiarities, idiosyncrasies, and all the associations 
in the life of the individual must be considered in connection with the 
general and local symptoms of the neurasthenic state. Great stress must 
be placed upon the study of individual symptoms, their mutual rela- 
tionship, and their changeable occurrence. In gastric neurasthenia 
gastralgia is more diffuse than the pain of ulcer or cancer of the stom- 
ach. It is not so much dependent upon food as either of the others, 
particularly ulceration. In gastric neurasthenia vomiting is rare. The 
vomiting is composed of mucus mixed with bile and food in various 
stages of digestion. It is never bloody, nor does it contain decomposed 
masses. Hysterical vomiting occurs with ease and regularity compared 
with the vomiting of neurasthenia. The vomiting in neurasthenia is 
bitter, due to the presence of peptones. In gastric neurasthenia the 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 805 

stools are changeable in character. They do not contain undigested 
remnants of food, or mucus, or blood. The form of the feces is variable. 

Differential Diagnosis. Neoplasms, ulcers, strictures, and dilatation are 
distinguished by physical signs or characteristic symptoms. In gastric 
neurasthenia the stomach should be empty seven hours after taking a 
meal. The results of the chemical examination are not sufficiently 
definite for diagnostic purposes, for at times the same chemical changes 
are present, as in ulcer, carcinoma, and chronic catarrh. The diag- 
nosis must be based largely, as previously intimated, upon prolonged 
observation and a carefully taken history, and upon the general condi- 
tion of the patient. The cases must not be mistaken for costal neural- 
gia, although it is not usually easy to be led astray. Reflex gastric 
neuroses are seen, as indigestion, gastralgia, or vomiting. The types 
are interchangeable, although vomiting occurs in the more acute reflexes, 
indigestion in the more chronic. The cerebral disorders which give 
rise to vomiting are meningitis, abscess, and tumor. The vomiting 
may be transitory, or may be persistent. There is usually hypersecre- 
tion of the gastric juice. The vomiting may usher in the disease or 
develop during its course. If vomiting is of long standing its possibly 
reflex origin should always be investigated. (See Vomiting.) 

Gastralgia is sometimes a reflex from lesions in the cervical and 
dorsal portions of the cord ; not only in the posterior columns, but also 
hi disseminated sclerosis. Vomiting occurs, and the attack is known 
as a gastric crisis. 

Chronic dyspepsia is a frequent reflex disorder of diseases of the 
sexual organs, as amenorrhoea and dysmenorrhea, in the climacteric 
period, and in chronic inflammations of the uterus. In malpositions 
and tumors, and in pelvic exudations with traction, in ulcers, in ova- 
rian tumors, the so-called dyspepsia uterina of Kisch is common. 

Chronic Gastritis. Causes. 1. Previous attacks of acute gastritis. 

2. The local irritation of badly cooked or poorly masticated food, 
and of alcoholic and other beverages. 

3. The local irritation of urea in chronic Bright' s disease, and of 
products of putrefaction in constipation. 

4. In anaemia chronic gastritis is of frequent occurrence, and in 
venous congestions from any cause, but particularly from disease of 
the heart or diseases which interfere with the portal circulation. It 
occurs secondarily to diabetes, gout, rheumatism, nephritis, and tuber- 
culosis. 

5. It is a constant attendant upon local disease of the stomach, as 
cancer, dilatation, and ulcer, and of local disturbance of the circulation. 

The symptoms are those of chronic indigestion. There is a dry, 
pasty, or salty taste in the mouth, especially in the morning. The 
tongue is coated over its entire surface, or has red patches at the base ; 
its papilla? are always swollen and its edges marked by the teeth. 
Aphthae recur frequently. The lips are dry and often chapped. 
The appetite is poor or capricious. Although there is no great 
thirst, the patients crave fluids with their meals, and acid drinks are 
grateful. After eating there is a feeling of oppression and disten- 
tion in the epigastrium, frequently followed by belching. The gaseous 



806 SPECIAL DIAGNOSIS. 

eructations are odorless or foul, and rancid regurgitation with pyrosis 
is frequent. The acidity is due to fatty acids and not to hydrochloric 
acid, as in hypersecretion. Vomiting is invariably present, but occurs 
irregularly. It is usually preceded by nausea. The most character- 
istic form is that in which mucus is vomited in the morning on rising. 
Constipation usually exists ; it may alternate with diarrhoea. There 
are flatulency and rumbling in the intestines. 

General Symptoms. The nervous symptoms are the most pronounced. 
The mental activity is diminished, there is a feeling of languor or 
torpor, especially after eating. Headache is frequent after eating, and 
the patient may become morose and hypochondriacal. Attacks of ver- 
tigo are common. Itching of the skin and coldness of the extremities 
are not rare. Sleep is deeper and longer than is natural, but is dis- 
turbed by dreams, and is not refreshing. Yawning is frequent. Phar- 
yngitis usually attends the attack, with hacking cough and expectora- 
tion, or hawking of mucus. 

The pulse may be weak and irregular, and at times there is an even- 
ing rise of temperature. The urine is scanty, high-colored, and usually 
loaded with urates. 

Three forms are seen : (1) Simple chronic gastritis ; (2) chronic 
mucous gastritis ; the term " chronic catarrh of the stomach " is applied 
to both conditions. If the condition lasts a long time, it results in (3) 
atony, with dilatation of the stomach, or with atrophy. Atrophy, or 
atrophic gastritis, is secondary to the chronic form, or to stenosis of the 
oesophagus, or to cancer. The symptoms are those of pernicious anae- 
mia. Cirrhosis of the stomach is also a sequence of gastritis. It is 
rare, and the symptoms are not characteristic of a spinal lesion. They 
are those of the primary disease. 

Examination of the Stomach-contents. In simple gastritis the stom- 
ach, after digestion is completed, contains a small amount of slimy 
fluid. Hydrochloric acid is diminished in quantity after a test-break- 
fast ; lactic acid and the fatty acids are present, as previously noted. 
Pepsin and the milk-curdling ferment are absent or diminished. In 
mucous gastritis there is subacidity. It differs from the simple form 
in the excess of mucus only. In atrophy the hydrochloric acid and 
pepsin are diminished, or absent altogether after the test-breakfast. 
The fasting stomach is empty. There are no fermentation acids. 
Atrophy must be distinguished from cancer and subacid neuroses. 
The latter occur in younger individuals than those subject to atrophy. 
A bloody tinge in the stomach-contents, or hemorrhage, may be the 
only distinguishing mark of cancer. It is often impossible to make 
a diagnosis. 

Diagnosis. The diagnostic features of chronic gastritis are : First, 
long duration ; second, persistence of local symptoms ; third, recur- 
rence of local symptoms after food, the symptoms being aggravated by 
stimulants, or stimulating food ; fourth, moderate pain ; fifth, absence 
of cachexia ; sixth, absence of tumor • seventh, flatulency. Hemor- 
rhage is rare, and there may or may not be vomiting, while the quan- 
tity of hydrochloric acid is variable. Finally, the cause is usually 
definite. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 807 

Dilatation of the Stomach (Gastr ectasia). (See Plate XXXVIIL, 
Fig. 1.) It is caused by obstruction at the pyloric orifice, either from 
cancer, the cicatrix of an ulcer, or fibrous stricture. It follows atony 
and degeneration of the walls of the stomach which occur in the course 
of chronic gastritis. It may attend paralysis of the stomach. Excessive 
eating or drinking are the only probable causes independent of organic 
disease. Hence, we have (1) obstructive and (2) atonic dilatation. 

The dilatation may be acute. The term acute paralytic distention is 
also applied to this condition. The cases are extremely rare. There 
is sudden enlargement of the upper portion of the abdomen, with 
pressure upon the surrounding structures. The heart is dislocated and 
its action much interfered with ; collapse follows and may end in 
death. At first there may be some belching, but the patient is soon 
unable to remove the gas, and suffers from extreme discomfort, palpi- 
tation, and dyspnoea. The vomiting may occur at once or later. It 
is persistent and excessive. On physical examination the stomach 
yields the same physical signs as in chronic dilatation. 

Chronic dilatation develops slowly. The symptoms of it are super- 
imposed upon the causal disease. There is marked dyspepsia, with 
flatulency, pyrosis, and other symptoms of fermentation. The tongue 
is pale and furred, or red, smooth, and shiny ; or it may be soft and 
flabby. If frequent vomiting has attended the causal disease, it now 
occurs at longer intervals ; the amount is excessive, greater than the 
normal stomach would hold, and is made up of partially digested and 
fermented food and large amounts of mucus. The stomach-contents 
contain sarcinse, torulse, and other products of fermentation. Hydro- 
chloric acid is usually absent, but there is a large excess of lactic 
and fatty acids. The patient loses flesh and strength ; becomes irri- 
table, depressed, and more or less melancholy. The patient is subject 
to vertigo and to attacks of nocturnal asthma. The nervous symptoms 
of chronic gastritis are also present. 

Sleeplessness is quite common. In some cases there is excessive 
thirst because of the small amount of nutriment and fluid absorbed. 
Cardiac palpitation and irregularity are common, and dyspnoea may 
occur on account of the distention. Tetany has been observed in cases 
of dilatation, especially after lavage. 

Physical Examination. The diagnosis is not complete without physi- 
cal examination. On inspection the abdomen is large and prominent, 
and the outline of the stomach can sometimes be seen. Peristaltic 
movements of the organ are often seen. The movement is from left 
to right. The heart is lifted upward. On palpation the peristalsis can 
be felt, and with one hand on the stomach, tapping with the other, a 
splashing sound can be detected. Or the hand may be placed over the 
stomach (patient standing) and the body quickly shaken. On palpa- 
tion the striking or pushing hand should be compressed over the false 
ribs. A tumor can sometimes be felt in the region of the pylorus, or 
below the umbilicus. On percussion, when the stomach contains gas, 
a tympanitic note is heard. After drinking water dulness may be de- 
tected between gastric and intestinal tympany if the patient stands up. 
The dull note disappears when he resumes the recumbent posture. 



808 SPECIAL DIAGNOSIS. 

Before taking water tympany is not so marked in the upright as in 
the recumbent posture, because the stomach is dragged back or down. 
The tympany extends high up in the chest on the left side, so that 
Traube's half-moon space is exaggerated. It may extend as high as 
the fourth interspace on the left side. Cardiac dulness is increased 
and the apex of the heart is lifted upward and to the left. In the 
axillary region the tympany may extend as high as the sixth rib. 
There is usually atrophy of the spleen, so that unless very careful 
light percussion is performed the splenic dulness cannot be brought 
out. The lower limit extends below the transverse umbilical line, and 
may even extend midway to the pubis. If there is gastroptosis, the 
half -moon space becomes dull on percussion, the stomach tympany fall- 
ing to a lower level. On auscultation succussion can easily be elicited. 
Sometimes the sound is sizzling, as if there was effervescence. Heart- 
sounds may be transmitted clear and metallic over the tympanitic 
stomach. With auscultatory percussion the border of the stomach can 
often be denned accurately. Percussion must be commenced far away 
from the stomach-limit and conducted toward it. (See Examination 
of the Abdomen.) 

Stenosis of the Pylorus. Usually, obstruction is caused by malig- 
nant disease. Hypertrophic stenosis occurs in rare instances and leads 
to dilatation, as indicated above. The condition may be congenital or 
acquired. 

Acquired stenosis may be the result of chronic gastritis, or develop 
independently, sometimes as part of a general proliferation of connec- 
tive tissue. (See case of author, Path. Soc. Trans., vol. xi. 1881-83, 
p. 216.) If, to the physical signs of tumor of the pylorus, be added 
the signs and symptoms of dilatation, we have the clinical picture of 
hypertrophic stenosis of the pylorus. It is extremely rare to find 
complete obstruction. 

Congenital hypertrophic stenosis, as Metzler and Caudley point 
out, has for its characteristic features : (1) Vomiting, occurring with- 
out apparent cause and persisting in spite of treatment ; (2) the ab- 
sence of bile from the vomited matter ; (3) obstinate constipation ; (4) 
marasmus ; (5) the presence of a tumor in the region of the pylorus ; 
(6) the absence of abdominal distention except from dilatation of the 
stomach itself in some instances ; and (7) the absence of signs or 
symptoms of gastritis and of the more common forms of intestinal 
obstruction. Diagnosis depends entirely on the characteristic symp- 
toms arising during the first few weeks of life and the presence of a 
tumor. 

Diseases of the Stomach Characterized by Pain and Vomiting. 

Cancer of the Stomach. The clinical symptoms are varied. Gas- 
tric cancer may occur Avithout any symptoms whatever, and be discov- 
ered after death from other causes. On the other hand, general maras- 
mus and cachexia may be present, without local symptoms. In some 
cases the gastric symptoms are slight, and obscured by the symptoms 
of secondary growtli in the liver or peritoneum. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 809 

Tvpical cases are those which occur late in life, with symptoms of 
chronic gastritis. These symptoms may continue for months before 
anything further is observed. Gradually the uneasiness and discom- 
fort after eating increase to actual pain. Loss of appetite is marked, 
and in spite of careful treatment there is loss of flesh and strength. 
The usual vomiting of chronic gastritis gradually becomes more fre- 
quent. The general appearance of the vomitus is at first like that of 
chronic gastritis. Soon it becomes streaked with blood, or a moder- 
ately large hemorrhage may take place. The vomited matter is dark 
in color, like coffee-grounds in appearance. The relation of vomiting 
to the time of taking meals depends upon the seat of the disease. If 
at the cardiac end of the stomach, the vomiting may take place at 
once. If in the greater curvature, within twenty minutes or one 
hour and a half after taking food. If at the pyloric orifice, the vomit- 
ing is delayed several hours. As the disease advances, and obstruc- 
tion becomes more complete at the cardiac orifice, food is immediately 
regurgitated, unless secondary dilatation of the oesophagus takes place. 
When there is gastric dilatation the vomiting may take place at longer 
intervals and be characteristic of the vomitus of dilatation. Constipa- 
tion is the rule. 

Tumor. After the symptoms of chronic gastritis have continued for 
some time without relief a tumor may be detected, depending upon its 
situation and size. (See Tumors of Abdomen.) If the growth is situ- 
ated at the cardiac orifice of the stomach, it is often impossible to 
detect it. If at the pyloric orifice, the tumor is found to the right of 
the median line above the umbilicus, but may be forced down by 
the weight of the stomach and felt at the umbilicus. (See Plate 
XXXVIII. , Fig. 2.) When dilatation follows pyloric tumor it may 
be still lower down, as in a case of the writer's, in which it was found two 
inches below and to the right of the umbilicus. In tumor of the greater 
curvature the mass is detected below the margin of the ribs on the left 
side, and may be as low down as the umbilicus. If the greater curvature 
is involved, the organ usually atrophies, and hence the physical signs 
indicating the lower border of the stomach are higher up than in health. 

It is necessary to exclude tumors due to other causes. This is some- 
times difficult — indeed, as far as the location and physical characters 
are concerned, often impossible. The most pronounced diagnostic 
feature of tumor of the pylorus is the occurrence of secondary dilata- 
tion of the stomach. For a differential diagnosis of tumors in this 
region, see Palpation of Abdomen. 

Symptoms due to Metastasis. The liver is the most frequent seat of 
secondary growths. The organ enlarges, and its surface is covered 
over with nodules. (See Plate XXXVIII. , Fig. 2.) Jaundice occurs 
in rare instances. The enlarged liver mayGOver the stomach and hide 
the local mass. The inguinal glands enlarge. At times there is en- 
largement of the supraclavicular glands, suggestive also of intra-abdom- 
inal carcinoma, from other causes. 

The general symptoms are those of emaciation and cachexia. The 
emaciation is extreme, and in some cases may be out of proportion to 
the local symptoms. 



810 SPECIAL DIAGNOSIS. 

The symptoms of cachexia are those of emaciation and anaemia. 
The ancemia becomes profound. The pallor of the face is striking, 
often it is of a yellowish and straw-colored hue. It must not be con- 
founded with jaundice — examination of the conjunctivae is usually 
sufficient to distinguish the two. The skin is flabby, and the subcu- 
taneous fat is entirely lost ; the emaciation is not so marked as in cancer 
of the oesophagus, except when there is complete cardiac stricture. 
The nutrition of the skin suffers, boils are common, and ulcers may 
occur. Subcutaneous hemorrhages are seen in the terminal stages on 
the backs of the hands, on the dorsum of the feet, on the legs and 
arms. There is slight oedema of the ankles. 

General atrophy of the internal organs takes place, so that the heart 
becomes small ; it loses its strength, the patient becomes weaker and 
weaker, the pulse rapid and feeble. 

If fever occurs in the course of the disease, it is usually due to sec- 
ondary accidents, as suppuration in a tumor, or perforation with septic 
peritonitis. The usual course of the temperature is normal until the 
later stages, when it is subnormal. 

Examination of the Stomach-contents. Hydrochloric acid may or 
may not be absent, depending upon the amount of gastric catarrh. 
Lactic acid, on the other hand, is commonly present even in the earli- 
est stages, and when associated with absent HC1 is very diagnostic. 
Boas' test-breakfast must be given. For an accurate diagnosis re- 
peated examinations must be made. Other general and local condi- 
tions, as fevers on the one hand, or dilatation on the other, are attended 
by absence of hydrochloric acid at times. In carcinoma it is the per- 
sistence of the absence which is diagnostic. Pepsin and the milk- 
curdling ferment are not changed. 

The Urine. Indican in increased amount, acetone and diacetic acids 
may be present in the urine ; otherwise there is no change. 

Diagnosis. In the diagnosis of gastric cancer the following must be 
borne in mind : 1. The age of the patient. 2. The occurrence of 
causeless dyspepsia without relief. 3. Rapid loss of flesh and strength, 
with cachexia. 4. The occurrence of pain in the epigastrium, contin- 
uous, increased by food, but not relieved by vomiting, as in ulcer, 
and not distinctly localized. 5. Tumor — hard, circumscribed, fol- 
lowed by the physical signs of dilatation, if in the pylorus. 6. Vom- 
iting is necessarily associated with the taking of food, in which frag- 
ments of cancer may be found ; blood-cells are common ; they may be 
detected on microscopical examination, or by the test for hsemin. 7. 
Examination of stomach-contents, (a) Except in dilatation the fasting 
stomach is empty ; (6) hydrochloric acid is often absent, whereas lactic 
acid is present ; (c) delayed absorption is present, indicated by motor 
tests. 8. Hemorrhage. In small amounts, usually of characteristic, 
coffee-ground appearance. 9. Metastases — above the left clavicle ; in 
the liver ; in the inguinal glands ; rarely in the lungs and peritoneum. 
10. Eichhorst speaks of persistent itching of the skin and insomnia as 
characteristic symptoms. 11. Finally, the comparatively short dura- 
tion of the case. Rarely does it extend over a period of two years. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 811 



Differential Diagnosis of Gastric Cancer, Gastric Ulcer, and 
Chronic Gastritis. (Welch.) 



Gastric Cancer. 

1. Tumor is present in three- 
fourths of the cases. 

2. Rare under forty years of 



Average duration about one 
year, rarely over two years. 

Gastric hemorrhage fre- 
quent, but rarely profuse ; 
most common in the ca- 
chectic stage. 



5. Vomiting often has the pe- 
culiarities of that of dila- 
tation of the stomach. 



Free hydrochloric acid usu- 
ally absent from the gastric 
contents in cancerous dila- 
tation of the stomach ; lac- 
tic acid much increased. 



10. 



Gastric Ulcer. 



Tumor rare. 



Chronic Catarrhal Gastritis. 
No tumor. 



May occur at any age after May occur at any age. 
childhood. Over one-half of | 
the cases under forty years 
of age. 



Duration indefinite 
for several years. 



Gastric hemorrhage less fre- 
quent than in cancer, but 
oftener profuse ; not uncom- 
mon when the general 
health is but little im- 
paired. 

Vomiting rarely referable to 
dilatation of the stomach, 
and then only in a late stage 
of the disease. 

Free hydrochloric acid usu- 
ally present in the gastric 
contents. 



may be Duration indefinite. 



Gastric hemorrhage rare. 



Vomiting 
present. 



may or may not be 



Cancerous fragments may Absent, 
be found in the washings 
from the stomach or in the 
vomit (rare). 

Secondary cancers may be Absent, 
recognized in the liver, the 
peritoneum, the lymphatic 
glands. and, rarely, in other 
parts of the body. 



Free hydrochloric acid may be 
present or absent. 



Absent. 



Cachectic appearance usually 
less marked and of later 
occurrence than in cancer, 
and more manifestly depen- 
dent upon the gastric dis- 
orders. 



Loss of flesh and strength 
and development of ca- 
chexia usually more mark- 
ed and more rapid than in 
ulcer or in gastritis, and 
less explicable by the gas- 
tric symptoms. 

Epigastric pain is often Pain is often paroxysmal, 
more continuous, less de- , more influenced by taking 
pendent upon taking food, food, oftener relieved by 
less relieved by vomiting, vomiting, and more sharply 
and less localized than in localized than in cancer, 
ulcer. 



11. Causation not known. 



Causation not known. 



Absent. 



When uncomplicated, usually no 
appearance of cachexia. 



The pain or distress induced by 
taking food is usually less severe 
than in cancer or ulcer. Fixed 
points of tenderness usually ab- 
sent. 



Often referable to some known 
cause, such as abuse of alcohol, 
gormandizing, and certain dis- 
eases, as phthisis. Bright's dis- 
ease, cirrhosis of the liver, etc. 

May be a history of previous simi- 
lar attacks. More amenable to 
regulation of diet than is cancer. 



12. No improvement, or only Sometimes a history of one or 

temporary improvement, more previous similar at- 

in the course of the dis- tacks. The course may be 

ease. irregular and intermittent. 

Usually marked improve- 

i ment by regulation of diet. 

Cases of cancer of the stomach may present only symptoms of anae- 
mia. In this manner the disease has been confounded with pernicious 
ancemia. The blood is never reduced in cancer to the degree it is in 
pernicious anaemia, nor does it present the characteristics found in 
anaemia. 

Ulcer of the Stomach. Simple round ulcer of the stomach may 
occur at any age ; but is most common in young anaemic women. It 



812 SPECIAL DIAGNOSIS. 

may be the result of an erosion of hemorrhagic infarcts by the gastric 
juice. Stockton believes it to be a neuropathic change. 

The Symptoms. The symptoms are variable. The cases have 
been divided by Welch into four classes : (1) Those in which there are 
no symptoms whatever, the ulcer having been found after death from 
other diseases ; (2) no symptoms until the sudden occurrence of hemor- 
rhage, or perforation ; (3) the symptoms of chronic gastritis or gastral- 
gia only ; (4) typical cases, with the characteristic symptoms, pain, 
hemorrhage, and vomiting. The symptoms of gastric ulcer may develop 
suddenly. 

Pain. The pain is localized ; it is usually confined to a small area 
in the epigastrium. It may be seated behind the cartilage of the sixth 
and seventh ribs, or may be complained of in the back, between the 
eighth and ninth dorsal vertebrse, extending as low down as the first 
and second lumbar. It is of a burning or gnawing character, is in- 
creased by food, and comes on in from two to ten minutes after the 
ingestion of food. It is relieved by vomiting, or after the act of diges- 
tion is completed ; but a persistent, dull pain or a feeling of soreness 
remains. In addition to the ordinary pains, there may be attacks of 
gastralgia. The pain is increased by pressure. It may be modified 
by the position of the patient. It may be relieved by lying on the 
back when the ulcer is in the anterior wall ; or relieved by lying on 
the abdomen when in the posterior wall. 

Vomiting. Vomiting occurs shortly after the ingestion of food. It 
is not attended by retching. The vomited matter may contain blood. 

The vomited matter and the contents of the stomach contain hydro- 
chloric acid, which may be in excess. Eichhorst thinks it is always in 
excess. 

Hemorrhage. Blood in the vomitus gives it a brown or reddish 
color. It may be detected by the usual methods. Hemorrhage may 
occur, however, independently of the act of vomiting. It varies in 
amount from half a pint to a quart. It may be so severe as to cause 
collapse. Sometimes, instead of being discharged as a profuse hemor- 
rhage, the blood may gradually ooze from, the ulcer and collect in the 
stomach before being vomited. It is then altered by the acid gastric 
juice. Sometimes the blood is not vomited, but passed by stool, which 
is then tarry. Tarry stools also follow the vomiting of blood. In the 
course of ulcer a hemorrhage may be so severe that death takes place 
before vomiting occurs. The stomach is then found to be filled with 
blood. 

The stomach bougie should not be used ; the nature of the contents 
must be determined by an examination of the vomited matter. 

The General Symptoms. If the cases are of long standing, the 
face is anxious and the lines are sharpened. If there is much hemor- 
rhage, anaemia ensues. There is not much wasting and no fever. 
Chronic dyspepsia and constipation may be present during the intervals 
in which the severe symptoms are in abeyance. The period of abey- 
ance varies, and the symptoms may come on without cause, as in gas- 
tric crises, during which time the vomiting may persist for two or three 
days. I saw a young girl of twenty years with most severe gastric 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 813 

hemorrhage and classical symptoms of ulcer. With careful treatment 
she improved. After marriage she remained well until pregnancy. 
During the first periods of this condition vomiting was extreme ; it 
then subsided, whereupon, without warning, a gastric crisis took place. 
The vomiting of blood continued for many days, and the symptoms of 
gastric ulcer remained for a month. 

One of the characteristic features of the disease is the recurrence of 
symptoms after a long period of abeyance. A patient under my care 
during the last ten years has had three undoubted attacks. It is pos- 
sible that during each period ulcers healed, to be followed after a time 
by the occurrence of new ulcers. 

Diagnosis. The diagnostic features are : 1. The age. 2. The long 
duration. 3. The occurrence of emaciation up to a certain point only ; 
most of the patients are under-weight and have a gaunt look, particu- 
larly males. 4. The characteristic pain. 5. The vomiting. 6. The 
hemorrhage. 7. The periods of relief from symptoms. 8. The absence 
of marked nervous symptoms which attend gastric neuroses. 9. The 
absence of dilatation of the stomach. 10. The hyperacidity of the 
gastric juice. 

The Accidents of Ulcer of the Stomach. 1 . The occurrence of perfo- 
ration. Sudden severe pain, with collapse. The pain is usually in 
the epigastrium, but may be in the back as high as the seventh or 
eighth dorsal vertebra. 

2. Hemorrhage, which may cause death immediately, with either 
vomiting of blood or retention in the stomach. 

3. With healing of the ulcer, stenosis at the pyloric orifice may take 
place, with subsequent dilatation of the stomach. 

Diseases of the Intestines. 

The intestine is a canal of varying dimensions, the physiological 
office of which is to propel material received from the stomach, and to 
permit of the digestion and absorption of that which is to serve for the 
nutrition of the body. The canal is richly supplied with bloodvessels 
and lymphatics. It is made up of mucous membrane, muscle, and 
peritoneum. For the purpose of digestion, fluids are secreted, either 
from the intestinal glands or large neighboring glands which discharge 
into the canal. 

Diseases which affect the canal impair or cause an abeyance of the 
physiological offices. As these offices — absorption and digestion — are 
essential to nutrition, it is not surprising that the body-weight and 
strength are impaired. We know too little about the function of diges- 
tion to utilize such knowledge in diagnosis. Intestinal digestion is 
also dependent upon the' healthy performance of the functions of the 
liver and pancreas. It is difficult to draw fine lines of distinction even 
in health, and intestinal pathology is closely interwoven with hepatic 
and pancreatic pathology. 

Alterations of the function of the intestine as a canal give rise to dis- 
tinctive symptoms. Either its movements are too frequent and rapid, 
causing diarrhoea, or too sluggish, causing constipation. Obstruction of 



814 SPECIAL DIAGNOSIS. 

the canal leads to symptoms common to such a condition (see Morbid 
Process), modified by the physiological duties and the anatomical 
structure of the canal. 

The morbid processes are hyperemias, inflammations, degenera- 
tions, and new growths. The symptoms that attend these processes 
are not different from the symptoms that attend such processes in 
similar structures elsewhere. It must not be forgotten that the function 
of the canal is influenced by each process. On account of the process 
we may have pain and fever ; on account of the impaired function, 
pain, flatulency, diarrhoea, or constipation, change in the character of 
the stools, and impaired nutrition. Some of the above morbid processes 
may lead to the mechanical condition, obstruction. 

The morbid alterations of the intestinal tract are ascertained by 
data obtained by inquiry and by observation. The data obtained by 
inquiry include the subjective symptoms — pain, and discomfort from 
flatulency. By observation the general condition of the patient, the 
presence of tenderness, alterations in the size and shape of the abdo- 
men, and other physical phenomena are observed. The feces are care- 
fully studied, with the object of determining modifications of the 
function of the bowel, the presence of ingredients due to some morbid 
process, as serum, blood, pus, or mucus, or of extraneous matter, as 
worms or foreign substances. The feces are studied by the naked eye, 
by the microscope, and by bacteriological methods. 

One symptom may be the chief manifestation of a disease, as pain 
of lead-colic, diarrhoea of several morbid disorders, constipation of 
others. In the discussion of the special symptoms a consideration of 
the diseases of which the symptom is the main expression will be 
taken up. 

Parasites. The intestine is the recipient of material for nutrition. 
Parasitic forms of animal life, or their ova or spores, may enter the in- 
testine with the food. They either remain in the intestinal tract or 
wander into other structures. They include animal and vegetable 
parasites, such as forms of protozoa, vermes, and fungi. While the 
canal is open to infection by various micro-organisms, it is the natural 
habitat of others, which may become deleterious agencies when the 
conditions of their environment are changed. Thus the bacillus coli 
communis is, in man, with normal epithelial structure and normal 
secretions, an innocuous parasite which, when inflammation sets in, 
may become nocuous. 

The symptoms produced by the protozoa and fungi, or by their prod- 
ucts, the ptomaines, are of an infectious or toxic nature. Inflamma- 
tion is produced locally. 

The symptoms of worms, if retained in the intestinal canal, are : (1) 
Keflex in nature ; (2) symptoms due to catarrhal inflammation ; (3) 
symptoms due to action of the parasite on the blood — anaemia ; (4) 
symptoms due to wandering of the parasite, as in trichinosis. (See 
Feces.) 

Symptoms of the Taznioz and Bothriocephali. There may be no symp- 
toms save discharge of the parasite or portions of it by the rectum. 
In others the symptoms of intestinal dyspepsia or intestinal catarrh 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 815 

are observed. Headache, giddiness, lassitude, and itching at the nose 
and at the anus are said to be present. The patient becomes hypo- 
chondriacal. Convulsive disorders occur. Hysteria, forms of epilepsy, 
grinding of the teeth at night, and restlessness attend the habitation of 
the parasite in the intestine. In all convulsive disorders the possi- 
bility of worms as a cause must be remembered. 

Symptoms of Ascarides. (1) Gastro-intestinal catarrh ; (2) symp- 
toms of obstruction (rare) ; (3) symptoms due to wandering — as to the 
hepatic duct to the stomach, or to the vagina ; (4) nervous symptoms 
of reflex origin ; (5) the worm or its ova in the feces. 

Symptoms of Oxyuris Vermicular is. (1) Gastro-intestinal dyspepsia 
or catarrh ; (2) itching or heat at the anus, worse in bed ; (3) vesical 
and rectal tenesmus ; (4) erythema about the anus ; (5) priapism ; (6) 
vulvitis and vaginitis ; (7) the worms in the feces. 

The Strongylus. The symptoms are local, with the symptoms of 
profound anaemia. The discovery of the ova in the feces distinguishes 
this form of anaemia from other varieties. 

The symptoms due to the presence of the trichina spiralis and filaria 
will be discussed in appropriate sections. (See Blood and Infectious 
Diseases.) 

The Intestines in other Diseases. The relationship of intes- 
tinal disorders to affections of other viscera will be discussed with each 
symptom. It must not be forgotten that derangement of this tract 
may have its origin in local causes or in causes remote from the intes- 
tinal tract, or in some general condition of the individual. Thus diar- 
rhoea may be due to inflammation which is primarily local, or which 
may be secondary to infection. Nothing is more common than to see 
diarrhoea in a general infection, such as septicaemia. In exophthalmic 
goitre the diarrhoea is not due to a local cause, but to some as yet un- 
known nerve disorder. Constipation may be due to central brain dis- 
ease, to a general condition like diabetes, or be of local origin. 

It must be remembered that the diagnosis of an intestinal lesion 
is never complete without determining its causes. Thus enteritis and 
ulceration occur in typhoid fever, in cholera, and in other infectious 
disorders, all of which are to be passed in review in making up a diag- 
nosis. Diarrhoea is a symptom in Bright ? s disease, and the causal rela- 
tionship must always be borne in mind. 

Differential Diagnosis. Intestinal disease or disorders are not usually 
confounded with disease of other structures. It is worthy of remark, 
as a fact which is sometimes overlooked, that symptoms of intestinal 
obstruction are frequently due to peritonitis. Tumors of the intestine 
must be distinguished from tumors of the peritoneum, the stomach, 
pancreas, and liver, and the uterus and ovaries. The history, the seat 
and physical character of the tumor, and the associate symptoms point 
to the true condition. 

Arteries of the Intestine. The intestines are supplied by the mesen- 
teric arteries. Its branches may become the seat of emboli. The 
symptoms are sudden pain, intestinal hemorrhage, and discharge of a 
portion of intestine. The patients are the subjects of atheroma or heart 
disease. 



816 SPECIAL DIAGNOSIS. 

The Subjective Symptoms. 

The Data Obtained by Inquiry. Pain. Colic. Colic is the term 
applied to paroxysmal pain in the abdomen. It is characterized by 
suddenness of onset and by alteration of intestinal function. It attends 
all forms of inflammation of the intestinal tract. It is applied to a 
peculiar affection known as lead-colic, due to local effects of lead. The 
term colic is also applied to painful affections of the hepatic ducts, 
pancreatic ducts, the ureters, and the uterus. Intestinal colic is the 
form at present referred to. In addition to the inflammation of the 
intestinal tract, it may be due to indigestion with flatulency. When it 
occurs suddenly without local cause it is known as enteralgia. 

Intestinal Colic. The colic of intestinal indigestion occurs sud- 
denly, or it may be preceded by signs of intestinal indigestion. The 
pain is chiefly in the umbilical region and radiates from that point. 
It is relieved by moderate pressure or warmth. The patient is rest- 
less and irritable. The face is anxious. The pain causes him to 
roll about and double up. There is a cold sweat, and the pulse is 
small and hard. Prostration or collapse rapidly ensues. Nausea and 
vomiting follow the pain, and there are gaseous eructations. Disten- 
tion. The abdomen is distended and tympanitic on percussion. The 
pain may be relieved by the passing of flatus. Cramps. Spasm of 
the muscles of the calves is common. The cramps are very painful ; 
the muscles become knotted. The hands and feet are also cramped. 
The pain is said to be due to spasm of the intestine, and is known also 
as spasmodic colic. It is certainly due to distention or to irritation. 

If the intestinal colic is due to indigestible food, it may have been pre- 
ceded by an attack of acute indigestion, and the griping pains may 
have developed at long intervals, with gastric and intestinal flatulency. 
Vomiting may precede or attend the attack, and diarrhoea follow. If 
the colic is due to gas alone, there is great tympanites. If it is due 
to feces, it has been preceded by a history of constipation, and there 
may be fecal masses detected in the rectum or along the colon. 

Fever. The presence of fever is against intestinal colic, and points 
to inflammation in some portion of the abdomen ; moreover, in inflam- 
mation the pain is constant, but localized and aggravated by pressure. 
The skin is hot and dry. 

Diagnosis. The sudden severe pain, often relieved on the discharge 
of gas, with gastro-intestinal disorder, tympanites, the occurrence of 
cramps in the extremities, and the localization of pain to the umbili- 
cus, all point to the true nature of the affection. A history of indis- 
cretion in diet, or exposure, aids in the diagnosis. In colic the pain 
may come on suddenly, or increase gradually from a sense of discom- 
fort or soreness. The pain at its height is described as agonizing, and 
of a boring or shooting character, abating for a time and then in- 
creasing, until the patient rolls and twists in agony and breaks out into 
a cold sweat. The pain may shoot from the seat of greatest intensity 
to the shoulders, back, chest, or iliac region. 

It must be distinguished from enteralgia. The latter comes on 
slowly and lasts for hours or days. The pain is situated around the 






DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 817 

umbilicus, and is relieved by deep pressure, although the skin may be 
hypersesthetic. Sometimes the abdomen is retracted ; there are no 
signs of indigestion, and flatulency and borborygmi are absent. 

Lead Colic. If the enteralgia is due to lead, there is a history of 
exposure to that metal. The blue-line on the gums, with obstinate 
constipation but no vomiting, and the occurrence of neuritis due to 
saturnine-poisoning, point to the true nature of the case. 

Hepatic Colic. In hepatic colic the pain is situated in the region 
of the liver, and may radiate to the shoulder or back. It is sometimes 
fixed in the right parasternal line about the cartilages of the sixth and 
seventh ribs. The attack is attended by vomiting, usually of bilious 
fluid. It occurs in women most frequently ; the patients are almost 
always over forty years of age. It may be followed by jaundice. There 
is local tenderness, and there may be some swelling in the region pre- 
viously mentioned. The bowels are constipated, and after the attack 
may contain gallstones. 

Renal Colic. In renal colic pain begins in the kidney and then 
extends along the ureter. It is always more localized to the right or 
left of the median line in the abdomen. It is more frequently in the 
lower portion of either of the upper quadrants, three inches to either 
side of the median line, depending upon the kidney affected. From 
this region the point of maximum intensity and of local tenderness 
moves to the lower quadrant toward the median line in the oblique 
direction, rarely getting an inch below the transverse umbilical line. 
The pain then extends to the region above the pubes and down the 
thighs. From the first there is increased frequency of micturition. 
The urine is scanty, high-colored, and may contain blood. With the 
free micturition relief follows. 

Local Peritonitis. Pain over the liver, spleen, and kidneys is gener- 
ally due to involvement of the peritoneal coverings of these organs, 
and partakes of the character of local peritonitis. It may, however, 
be due to malignant, ulcerative, or inflammatory disease, and the diag- 
nosis must be made by noting the character of the pain, its intensity, 
duration, seat, and the other general and local symptoms with which 
it is associated. 

Rectal Pain. Pain in defecation may be due to piles, internal or 
external, or to fissure, or may be the result simply of the passage of 
an unusually large, hard mass. Pain from fissure is most acute and 
spasmodic, and persists for some time after defecation. Fibroid stric- 
ture of the rectum causes more pressure and straining at stool than 
real pain ; but cancer is apt to be extremely painful. 

Uterine Colic. In uterine colic the pain is situated in the pelvis. 
There is some abnormality of discharge, and a history of uterine dis- 
ease. Care must be taken not to confound the sudden pain of extra- 
uterine pregnancy with intestinal colic or other forms of abdominal 
pain. In extra-uterine pregnancy the pain is in the lower quadrants of 
the abdomen to the right or left of the median line. It is sudden and 
intense, attended by more or less collapse. It may be attended by 
all the symptoms of internal hemorrhage. It may cause vomiting. 
The history of cessation of menses, or other signs of pregnancy, of 

52 



818 SPECIAL DIAGNOSIS. 

discharge of decidua, with the local signs on physical examination > 
indicate the true nature of the pain. 

Pancreatic Pain. In disease of the pancreas, either from the passage 
of calculi (extremely rare) or because of pancreatic hemorrhage, there 
may be sudden severe pain. The pain is localized to the region below 
the sternum. It may be severe in the back and extend up the thorax. 
It occurs in paroxysms, and is attended by great anxiety and collapse. 

Gastric Pain. Intestinal colic must be differentiated from pain 
of gastric ulcer, gastric cancer, and gastralgia. The characteristics of 
pain in these affections have been discussed. When perforation occurs 
in gastric ulcer the pain is usually seated in the epigastrium, but may be 
complained of in the back as high as the mid-scapular region. It is 
sudden and severe, preceded by a history of ulcer and attended by 
collapse. There are no evidences of indigestion. Perforation of the 
biliary passages is attended by pain in the hepatic region. The pain 
is sudden and is usually preceded by symptoms due to derangement of 
the biliary passages from obstruction by gallstones. 

Appendicitis. Intestinal colic must not be confounded, although 
it frequently has been, with the pains that attend appendicitis. This 
is particularly the case with relapsing appendicitis. In this form only 
mild fever attends the attack. The patient is seized with severe pain, 
which may be described as occurring in the lower right quadrant, but 
is sometimes complained of about the umbilicus. It frequently follows 
indiscretion in diet, and may be attended by vomiting, and is likewise 
usually relieved by eructation, but not by the passage of gas, a point 
of great importance in the diagnosis. The attack occurs mostly in 
young subjects, and lasts from twelve to twenty -four hours. It may 
be so severe as to cause collapse. If fever attends it, and there is 
a mass present, the diagnosis is much easier. In the relapsing as well 
as the true form there is tenderness at McBurney's point. (See Ap- 
pendicitis.) 

Peritonitis. Intestinal colic must not be confounded with peri- 
tonitis, which may follow in any of the above conditions, or develops at 
other points in the abdomen. The purulent peritonitis that succeeds 
pyosalpinx may be attended by severe pain without much reaction. 
The pain, however, although complained of about the umbilicus, can be 
localized by pressure in the lower quadrant and in the pelvis. It may 
disappear after eight or ten hours, to be followed by a recurrence. 
The recurrence of pain is usually attended by fever. In the first 
twenty-four hours the bowels are loose, or at least readily moved. If 
the peritonitis continues beyond this period, it is often impossible to 
move the bowels. 

Intestinal Obstruction. Intestinal colic must not be confounded 
Avith organic disease of the bowels with resulting obstruction. In 
these affections there are sudden constipation and rapid prostration. 
The vomiting, if present, persists and soon becomes stercoraceous. In 
intussusception the stools are characteristic. Strangulation, or ileus, is 
associated with a history of previous peritonitis or the presence of hernia. 
In the latter there may be signs at the hernial points. In the obstruc- 
tion from external pressure the presence of tumors has been known 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 819 

previously or can be recognized. In fecal obstruction , or the obstruc- 
tion by gallstones, the local signs may be pronounced, and the pain is 
usually in the ileo-caecal region. The affection is acute. Pain that 
extends over a long period of time, that is not due to an acute process, 
or attended by sev3re acute symptoms, has been considered elsewhere. 
(See Abdomen.) 

Rheumatism and Neuralgia. Intestinal colic may be mistaken for 
rheumatism of the abdominal walls. In the latter there may be a 
history of exposure. The muscles are extremely tender. There are 
no gastro-intestinal symptoms, the urine is loaded with uric acid and 
urates, and there may be muscular pain in other situations, or a pro- 
nounced history of previous attacks of rheumatism. In lumbo-abdom- 
inal neuralgia the pain may simulate intestinal colic. Pressure-points, 
where the respective nerves have their exit through the fascia, are 
detected. 

Pain in Vertebral Disease. Just here may be considered the 
pain about the navel, which occurs in paroxysms, due to disease of the 
vertebrae. There may be caries from tuberculous disease or from 
pressure of an aneurism or malignant growths. Examination of the 
vertebrae may determine its nature. 

Diarrhoea. Diarrhoea is a symptom of disorder of the intestine, 
Avhich in turn is itself the cause of symptoms, just as jaundice, a symp- 
tom of hepatic disorder, is the cause of various symptoms. In diar- 
rhoea there is increased frequency of the movements of the bowels. 
This is due to increased peristalsis of the intestine, which occurs from 
a number of causes. Not all increased peristalsis results in diarrhoea. 
(A) Nervous diarrhoea. Increased peristalsis may be due to some im- 
pression upon the nervous mechanism of the intestine. This may 
explain the diarrhoea of emotion, or that which occurs from other 
psychical influences. (B) Catarrhal diarrhcea. In the larger number 
of cases the diarrhoea is due to catarrhal inflammation of the intestinal 
tract. The causes of the catarrhal inflammation are many, and have 
been divided into primary and secondary causes. Primary catarrh is 
due to the direct influence of causal factors upon the mucous mem- 
brane. (1) It is seen after cold or exposure ; (2) it occurs from the 
direct irritation of undigested food, and (3) from the action of irri- 
tants, as of bacteria or the products of bacteria. Catarrhal inflamma- 
tion due to micro-organisms is the most frequent form that occurs in 
children. 

Secondary catarrhs follow other lesions of more pronounced charac- 
ter, as ulcers. The catarrh, and hence the diarrhoea, that attends the 
ulceration of typhoid fever, the ulceration of dysentery, or that occurs 
in Bright' s disease, and the diarrhoea that attends carcinoma or other 
organic disease of the bowel, is of this nature. In addition, a catarrh 
of the bowels arises from venous stasis in the mucous membrane, with 
chronic congestion. This occurs in organic heart disease with conges- 
tion of the liver. 

Diarrhoea is a symptom of the action of certain poisons, such as 
mercury, arsenic, and other corrosive agents. The diarrhoea which 



820 SPECIAL DIAGNOSIS. 

occurs from the irritant action of food-products and in cholera infantum 
is due to a toxic ptomaine. 

Diarrhoea sometimes fulfils a vicarious office. This is the case with 
the diarrhoea which comes on in cases of chronic Bright's disease, and 
in acute Bright's disease before the supervention of uraemia. When 
diarrhoea occurs in a person with pallor, dimness of vision, and oedema 
the urine should always be examined. 

The Symptoms of Diaeehosa. The Motions. Increased move- 
ments of the bowels. The frequency of the movements varies with the 
cause. In the diarrhoea of nervous origin, usually after five or six 
movements have occurred, the patient is relieved, because by this time 
the cause for the nervousness has disappeared. In catarrhal diarrhoea 
the number varies from half a dozen in twenty-four hours to the same 
number in an hour. Indeed, in some severe cases the evacuations 
may be almost constant. 

Character of the movements. The movements may be (1) fecal, with 
a small amount of water. They are light in color, softer than natural, 
but yet retain their form. They are the kind of movements seen in 
simple catarrh. 

2. The fecal matter is mixed with undigested food. The feces are 
in scybalous masses, and the watery element is increased. They are 
the stools of the so-called dyspeptic diarrhoea. 

3. Along with the feces more or less mucus is seen. The amount of 
mucus depends upon the seat as well as the intensity of the inflamma- 
tion. Inflammations of the large intestine are attended with mucous 
discharge. It may be mixed with and stained by feces so that it can 
be recognized only by close inspection. In milder degrees of catarrh 
it is seen on the surface of the fecal masses. 

4. The feces disappear almost entirely, and instead the evacuations 
are watery. The watery evacuations may be discolored, as in the pea- 
soup evacuations of typhoid fever, or they may be almost clear water, 
as in the rice-water discharges of cholera. 

5. The evacuations may contain blood. Bloody discharge usually 
accompanies the discharge of mucus ; when the catarrh is in the lower 
bowel blood may occur independently of the mucus. If with the 
mucus, it tinges it in reddish specks, or small amounts of free blood 
are seen. The blood may be bright in color, and then usually comes 
from the rectum. It must be remembered that the blood may be from 
hemorrhoids, or fissure, which is unduly irritated by the diarrhoea. It 
is then bright red and unmixed with the movement, and from its 
position can readily be seen to have followed it. On the other hand, 
it may be due to cirrhosis of the liver, with venous congestion. It 
may be due to the ulceration of typhoid fever, and the intense inflam- 
mation of enteritis. It is a symptom of carcinoma of the bowel, and 
is of frequent occurrence, almost pathognomonic, in intussusception. 
It must be remembered that blood of this character is discharged from 
the bowel independently of diseases of that tube, as in purpura, scurvy, 
and other blood diseases. (See Arteries of the Intestines, page 815.) 
If mixed with the movement, the blood may be black, as in all forms 
of melcena, or it may be dark red in color. The black blood usually 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 821 

comes from the stomach or the first part of the duodenum, and may 
be the result of ulceration, or even from the swallowing of blood. 

Microscopical and Bacteriological Examination. (See Feces.) In 
simple catarrhal inflammation of the tubules, on microscopical examina- 
tion, but little is found except an excess of epithelium from the mucous 
lining. In more intense inflammations, in addition to epithelium, we 
find pus and blood and mucus. Micro-organisms are found, the kind 
depending upon the cause of the diarrhoea. In health, Booker has 
found at least forty varieties of micro-organisms, many of which, in 
all probability, are not pathogenic. In health, the bacillus coli com- 
munis and the bacterium lactis aeriformis are found. In the diarrhoea 
of children both forms are present in excessive numbers, because con- 
ditions favoring their growth arise, and in all probability are the cause 
of the irritation of the bowel. In that form of inflammation of the 
bowel known as dysentery, in addition to the bacteria that attend in- 
flammation, the amoeba coli is often present. It has been found that 
dysentery may be due to a number of causes, but that the so-called 
tropical dysentery is due to the protozoa first described by Kartulis, 
in Egypt, and in this country by Osier. (See Feces.) 

Pain. The symptoms that attend increased movement of the bowels 
depend upon the cause and also have direct relationship to the fre- 
quency of the evacuation. The most frequent symptoms are pain, 
flatulent distention, with borborygmi and tenesmus. The pain depends 
largely upon the cause. If the irritant is a product of indigestion, or 
a bulky mass, pain is more or less severe. It is situated in the centre 
of the abdomen, and may extend all over it. Pain occurs before the 
evacuation ; it is sharp, lancinating, and is usually relieved by the 
movement. If the inflammation is in the large intestine, the pain may 
be complained of in the course of the large bowel or be more intense 
over the caecum and the sigmoid flexure. The rectum may be the 
seat of pain or of painful sensations. This has been described as a 
feeling of a hot ball in the lower pelvis. 

Flatulent Distention. The flatulent distention is not very great 
generally. The abdomen is distended, tympanitic on percussion, and 
tender on palpation, both of which may be more marked in the middle 
of the abdomen if enteritis alone is present, or it may extend along 
the course of the colon, as in the so-called entero-colitis of children. 
With the distention there are borborygmi. The rumbling usually 
subsides after the evacuation. 

Tenesmus occurs in all forms of diarrhoea if the evacuations have 
been frequent. After the discharge of the contents of the bowel, par- 
ticularly if from the rectum, the tenesmus is much more severe, and may 
be of constant occurrence. In the severe cases the tenesmus may be 
almost continual. On account of it prolapse of the bowel is apt to ensue. 

General Symptoms. The general symptoms that attend diarrhoea 
depend upon the cause. In simple diarrhoea there might be slight 
feverishness only, with a little weakness. In diarrhoea, with excessive 
movements, with mucus, with or without blood, the fever is marked 
and may rise as high as 103°. The fever that attends dysentery is 
high, and usually rises rapidly at the beginning. 



822 SPECIAL DIAGNOSIS. 

Prostration. More or less prostration attends all cases. It is, how- 
ever, more marked when there are frequent watery evacuations. In 
its most pronounced degree it is seen in cholera and cholera infantum. 
Collapse rapidly ensues under these circumstances, on account of the 
depleting effects of the excessive watery discharge. In catarrh of the 
intestines secondary to typhoid fever and other conditions the general 
symptoms depend upon the primary disease. 

Chronic Diarrhcea. Chronic diarrhoea may be due to chronic 
inflammation of the bowels, as in chronic intestinal catarrh. It may 
be secondary to the ulceration of dysentery, tuberculosis, syphilis, or 
cancer. It is the common diarrhoea of amyloid disease. In chronic 
diarrhoea the number of the stools varies, but seldom amounts to more 
than ten to fifteen in a day. In chronic intestinal catarrh three or four 
movements occur in the twenty-four hours. They usually occur in 
the morning, the first evacuation taking place immediately on rising 
and the remainder during the morning hours. They are more com- 
mon in women than in men, and are readily excited by exhaustion or 
nervous influence, as grief, emotion, or excitement of any kind. The 
stools are fecal and watery, and contain some mucus. The mucus 
usually coats the surface of the feces. The color of the feces is not 
changed. The patients usually suffer fom intestinal dyspepsia, or they 
are subject to some gastric neurosis. They are not under weight, and 
except for the inconvenience of the morning hours, could attend to the 
ordinary demands of life. They are more nervous than most people, 
and are liable to attacks of hemicrania. 

Membranous Diarrhcea. In a number of cases the discharge 
from the bowels resembles membrane. The disease is also called 
membranous enteritis. The discharge contains much mucus, and may 
be quite watery. After the feces have been passed membrane is dis- 
charged. This may be in shreds or large masses, and may also be 
like a cast of the bowel. The patients are usually women who are 
hysterical and have some menstrual disorder. Pain may precede the 
discharge, and continue until there is complete relief. 

Constipation. Constipation may be due to a number of causes. It 
may be due to alteration or diminution in the secretions of the intesti- 
nal tract, as is seen in all fevers, except when they are attended by 
specific intestinal catarrh, as in typhoid fever. Such diminution of 
secretion occurs in the summer, when there is more free perspiration 
than in other seasons, and is present in affections attended by excess 
of perspiration, or exhaustive diuresis. Constipation, therefore, is a 
common symptom of diabetes. 

In addition to alteration of the secretion, diminution in the sensi- 
bility of the nerves may exist. This is the one chief cause of habitual 
constipation that is so prevalent. On account of carelessness the 
patient loses the habit of having a regular movement of the bowel 
each day, and in consequence the usual stimulus is removed. Consti- 
pation also occurs from weakness of the muscles. 

The three conditions — diminution or alterations in the secretions, 
debility of the muscles, and impairment of the sensibility of the ner- 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 823 

vous mechanism — are combined influences, on account of which consti- 
pation is so prevalent in persons of sedentary habits and in persons 
living upon improper diet. General diseases and local disorders which 
influence either of the above elements cause constipation. Thus in 
anaemia and chlorosis, in neurasthenia and hysteria, constipation is a 
common condition. Its occurrence in fevers has been mentioned. In 
the convalescence from exhausting disease and prolonged confinement 
to bed constipation is apt to ensue. 

Local Causes. Atony of the abdominal muscles or of the bowel 
is the cause. Atony is most strikingly seen in peritonitis and typh- 
litis, in both of which a paretic state of the bowels develops. It is 
seen in the aged and in cachexia along with atony of other muscles. 
Obstruction of the bowels, acute or chronic, usually causes constipation 
(q. v.). If the obstruction is not complete, there may be diarrhoea on 
account of catarrhal inflammation. Constipation often occurs on ac- 
count of pain, particularly pain seated in the rectum. The pain is 
such that the patient shrinks from an evacuation. Frequent postpone- 
ment soon causes constipation. The pain may be due to fissures, to 
hemorrhoids, or to fistula. Constipation occurs also from local dis- 
eases in other portions of the body, influencing, in all probability, the 
nervous mechanism by which peristaltic action is excited. In acute 
and chronic disease of the brain and cord, as meningitis and myelitis, 
constipation is a usual attendant. It also occurs in tetanus. If the 
bowel is deprived of fecal matter, evacuations cease ; constipation is, 
therefore, a common sign of stricture of the pylorus and of stricture or 
cancer of the oesophagus. 

Symptoms of Constipation. Constipation is characterized by diminu- 
tion in the frequency of the bowel-movements. The frequency of the 
movements varies in health. Some persons are comfortable with an 
evacuation taking place once a week, or at most every third or fourth 
day. There are cases on record in which the evacuations took place 
but once a month. Cases of this class are usually due to muscular 
paralysis of the bowels, with secondary dilatation. The accumulation 
of feces is removed by a sharp attack of diarrhoea, attended by much 
pain. The diarrhoea sometimes continues for twenty-four hours. When 
it sets in fever may be present until there is thorough evacuation. 

Local Symptoms. Usually the symptoms that attend constipation 
are local, being due to the discomfort of the accumulation of feces. 
The local symptoms may be limited to the rectum or extend through- 
out the abdomen. In the rectum there is a sensation as of the pres- 
ence of a mass, which may cause some pain. The abdomen is dis- 
tended; there is considerable rumbling, and sometimes peristaltic 
waves are seen. The accumulation of the fecal mass in the bowels 
may set up tormina and tenesmus, and portions of the mass may be 
discharged from time to time. In other words, a diarrhoea may occur, 
the diarrhoea of constipation, or spurious diarrhoea. The stools are 
small, composed of hard scybalous masses, generally coated with 
mucus, and streaked with blood. The evacuation does not give relief, 
and the desire for a movement may be more or less continuous. 

On examination in constipation with fecal accumulations the outline 



824 SPECIAL DIAGNOSIS. 

of the colon may be marked out by palpation and percussion of the 
distended abdomen. In its course masses are felt varying in size from 
a marble to a base-ball, and in consistence they may be soft to the 
palpating finger ; they are never indurated like a calcareous mass, as 
gallstones or a mass due to malignant disease. (See Fecal Tumor.) 

General Symptoms. While in many instances the general symptoms 
are of no consequence, in others the patients are nervous and may be 
in more or less impaired health, on account of the secondary effects 
upon the stomach. Digestion is impaired and the form of indigestion 
is that which attends neurasthenia. 

The patients are of spare habit, usually of dark or muddy complex- 
ion. They may be depressed. There is inaptitude for mental exer- 
tion ; they are more or less hypochondriacal. The tongue is constantly 
furred, the appetite variable ; there are weight and fulness after eating, 
and generally some flatulency. 

The Secondary Effects of Constipation. The effects of constipation 
upon the intestines are various and sometimes disastrous. They are 
dilatation and ulceration. The former may become enormous, as in 
cases reported by Formad and Osier. The dilatation may be so great 
as to distend the entire abdomen. The ulceration may be localized to 
the rectum, or caecum, or extend throughout the entire large intestine. 
On palpation the course of the colon is tender, and fecal masses may 
be outlined that are painful, because of their pressure upon the ad- 
jacent ulcer. In the rectum the ulcer may be deep, and be followed 
by peri-rectal abscess. 

Stercoral typhlitis. In the caecum the accumulation may cause a large 
boggy swelling, extending in the course of the caecum, which is tender 
on pressure and dull on percussion. 

Fecal impaction, with secondary ulceration, is of frequent occurrence 
in typhoid fever. This must be borne in mind, for often serious gen- 
eral and local symptoms arise because it is overlooked. Recently I 
saw a case with diarrhoea of constipation, with some fever, which per- 
sisted for weeks after the usual course of typhoid fever. It was 
thought the patient had tuberculosis, or that the typhoid process was 
abnormally prolonged. Examination disclosed ulceration into the 
vagina, and the feces were constantly discharged from this orifice. It 
had been thought that the discharges of feces were due to diarrhoea. 
Of course, fever attended the process, and rendered the case all the 
more obscure. 

In this connection must be mentioned the constipation that occurs 
on account of lead-poisoning, and the exhibition of drugs, as opium, or 
astringents. The constipation of lead-poisoning is usually attended 
by colic, and the blue-line on the gums is seen, while wrist-drop or 
other manifestations of lead may be present. 

Intestinal Hemorrhage. The causes are general and local. The 
general causes are those that accompany hemorrhage in other localities. 
(See Gastric Hemorrhage.) The local causes, when the hemorrhage is 
small, are : inflammation of the bowel ; traumatic injury to the bowel 
from hernia, feces, and parasites, and foreign bodies swallowed, or from 
corrosive poison ; tumors of the bowel, as in cancer, invagination, and 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 825 

ulcers. When the hemorrhage is large the causes are the congestion 
attending portal obstruction and liver disease, or disease of the heart 
with secondary obstruction ; aneurism of the superior mesenteric artery, 
or aneurism rupturing into the intestine, and, occasionally, embolism 
of the artery ; the ulceration from typhoid fever, from dysentery, and 
from syphilis. It may occur in pyaemia and septicaemia, or the acute 
exanthematous diseases. 

The symptoms may be those of hemorrhage alone : collapse, pallor, 
failure of sight, tinnitus, vertigo, small pulse, and general restlessness. 
The hemorrhage must be copious under these circumstances, and is 
due (1) to an ulcer, as in typhoid fever ; (2) to portal obstruction ; (3) 
to an aneurism ; (4) to purpura or haemophilia. 

A second group of symptoms is connected with the appearance of 
the discharges from the bowels. The stools are bloody ; if the hemor- 
rhage is low down, they are bright red and usually mixed with feces. 
If high up, they are tarry. The latter condition is known as melaena. 
(See Feces.) The passage of the stools is preceded by colicky pains, 
or there may be some rumbling. The diagnosis must be directed to- 
ward determining the cause of the hemorrhage, as well as its seat ; the 
history, the associate diseases, or symptoms, aid in determining the 
cause. Examination of the rectum may afford a clue to its origin. 

The Objective Symptoms. 

The Data Obtained by Observation. Physical Signs. (See 
The Abdomen.) Inspection. Local and general enlargements of the 
abdomen have been discussed in the preceding pages. Movements of 
the intestines are seen in obstruction due to increased peristalsis. The 
intestine above the point of obstruction may swell into a well-defined 
tumor which becomes hard and dull, and tympanitic on percussion. 

Palpation. Tenderness, peristalsis, peritoneal friction, the bubbling 
of gas through a constriction of the bowel, and tumors, are recognized 
by palpation. It is necessary often to place the patient on all-fours 
or in a knee-chest position. 

Percussion. The normal note is tympanitic. Local areas of dulness 
may be due to intestinal tumor. Light percussion should be employed. 
A dull tympany indicates a solid mass surrounded by the distended 
intestines. The outline of the large intestine can be ascertained by 
filling it with water. 

The Feces. General Considerations and Macroscopical 
Appearances. The number of stools in health varies chiefly with 
the individual and the character of the food taken. After infancy, 
one passage in twenty-four hours is the rule, but it is natural for some 
persons to have two or three, and for others to have but one passage 
in two, three, or four days. Such a condition is termed constipation, 
while pathological constipation is properly called obstipation. The 
opposite condition is known as diarrhoea. The amount and character 
of food and drink ingested influence the number of stools. Exercise 
also plays a role ; increased or diminished peristalsis, from whatever 
cause, will induce diarrhoea or constipation, respectively. In disease 



826 SPECIAL DIAGNOSIS. 

the greatest extremes are met with — from the non-passage of feces 
for days, as in obstruction, to an almost continuous discharge, as in 
some forms of intestinal inflammation. It is well to remember that 
diarrhoea may be the symptom of obstipation, as when impacted feces 
in typhoid causes looseness of the bowels. 

The amount of feces varies with the quantity and nature of food. If 
most of the food is digested there will be but little left to form feces. 
In any disease that prevents the absorption of digested food or causes 
an increase in the fluid contents of the intestine, as cholera, the amount 
of feces will be increased. In health about 140 to 200 grammes are 
voided in twenty-four hours. 

The form and consistence of healthy stools vary somewhat. They 
are commonly cylindrical and firm or mushy. When they remain long 
in the intestinal canal, and the water is extracted, they become hard 
and may form balls, or flattened masses known as scybala. These are 
frequently seen in convalescing typhoid patients. On the other hand, 
the feces may be without form, and are then liquid, either watery, as 
in cholera, or purulent or bloody. Many diseases cause such a con- 
dition. 

The odor of feces is sometimes more or less characteristic of certain 
conditions. Thus the stools of nursing infants have a sour smell, 
while in infantile diarrhoea, and when fermentation takes place, they 
have an odor of sebacic acid. When urine is mixed with the passage 
the odor will be ammoniacal ; with blood present it often has a stale 
odor. 

The reaction is not constant. Thus in intestinal catarrh, with acid 
fermentation, it will be acid, or in alkaline fermentation it will be 
alkaline. The color of the stool varies too much to be of special diag- 
nostic value. In health it is light to dark brown, due chiefly to the 
presence of hydro-bilirubin, a product of decomposition of bile-pig- 
ment, which is never normally found unaltered in the feces. It is 
influenced greatly by food and medicines. When certain berries, as 
huckleberries, are eaten, or certain medicines taken — iron and bismuth 
— they make the passages black. Calomel causes green stools, on 
account of the biliverdin discharged. Green stools may also receive 
their color from the presence of a bacillus which produces a green dye. 
Santonin, rhubarb, and senna cause yellow, and hsematoxylon red 
stools. The last fact is important, as parents or nurses should always 
be warned to expect red passages when hsematoxylon is given. 

The feces may be red or reddish from the presence of unaltered 
blood ; or black, when the blood has undergone changes ; the so-called 
" tarry stools " are of this character. With a decrease in the amount 
of bile the stools become less colored, and if the bile is cut off they 
become clayey. This color may, in some cases, be due to the presence 
of fat left undigested because of the lack of bile. On the other hand, 
if from disorders of the stomach and intestine the contents pass through 
too rapidly, the feces may contain unaltered bile, unchanged bile-pig- 
ment, giving a green or yellow color, and showing the bile-reaction. 

The constituents of feces that can be recognized by the naked eye are 
numerous. Seeds, stones, skins of fruit and berries, and the fibres of 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 827 

vegetables are often seen in healthy stools. In the passages of chil- 
dren and weak-minded individuals foreign substances of all descrip- 
tions may be present. Foreign bodies and partially digested portions 
of food may be mistaken for parasites. Portions of tumors from the 
digestive tract may appear in the feces. 

In certain diseases of the stomach and small intestine, and in those 
who eat very fast and do not properly masticate their food, undigested 
and unchanged particles of food may be seen in the stools. 

Shreds of mucous membrane of varying size are passed with the 
feces. Von Jaksch saw such a shred 5 cm. long and 3 cm. broad in a 
case of cholelithiasis. Various sized pieces of membrane, consisting 
of transformed mucus, are passed in membranous enteritis. 

Particles resembling sago-grains, perhaps the result of over-indul- 
gence in farinaceous food, have been met with. 

Gallstones in the feces have great clinical value. They may escape 
detection if not properly sought for. When suspected, each passage 
should be passed through a linen sieve, the fecal masses being softened 
with water. They may be found as small, crumbling masses, composed 
chiefly of cholesterin (intrahepatic calculi), or as hard, irregular, 
smoothly worn, shining, many-sided, hard stones, sometimes as large 
as an egg, usually the size of a pea. Enteroliths are occasionally seen. 
They are said to originate in the appendix. 

Blood may be present in the feces in varying proportions and con- 
ditions. When found unaltered on the surface of scybalous masses, ijt 
is from the rectum or large intestine, and probably the result of trau- 
matism. Hemorrhoids, if bleeding, may cause such an appearance, or 
may cause very free hemorrhage. Severe hemorrhage may come from 
ulceration of the rectum or colon, due to malignant disease or severe 
inflammation. The blood may be intimately mixed with the feces, 
and have its origin in the large intestine, but much more commonly it 
indicates a source in the stomach or small intestine. Under such cir- 
cumstances it is nearly always more or less changed by the intestinal 
juices, and is brownish-red or black (the tarry stool mentioned above), 
or has the appearance of coffee-grounds. The brighter the color of 
the blood the nearer is the source of hemorrhage to the anus. The 
more retarded the passage the greater the change ; while, if quickly 
expelled, blood from the small intestine may be passed unchanged, as 
in the hemorrhage of typhoid fever. The microscope detects blood 
when the naked eye fails to detect it. It is to be remembered that 
certain drugs, as already stated, may color the feces red, and simulate 
blood. 

Mucus may be present in the passages in health, but when in any 
marked quantity there is a catarrh of the mucous membrane of the 
intestines. When hard scybala are covered with mucus, or the mucus 
is seen in shreds, the large intestine is the seat of a catarrh ; although 
mucus may be mixed with thin stools, as in dysentery. Usually, how- 
ever, when the mucus is finely divided and mixed with the feces, it 
comes from the small intestine. Mucous shreds have already been 
mentioned. In cholera the particles of mucus look like boiled rice, 
hence the term " rice-water stool." 



828 



SPECIAL DIAGNOSIS. 



Fatty stools, to the naked eye, appear greasy or even clayey, when 
there is much fat, even though bile-pigment may be present. 

Pus may be present in large quantities from rupture of an abscess 
into the intestinal tract, or when there are ulcerations from various 
conditions, producing pus in considerable quantities. 

Mickoscopical Examination of the Feces. Many animal 
parasites are not microscopic, but it is convenient to consider them in 
the following paragraphs. A small portion of the solid feces to be 
examined is placed on a slide, moistened with a J per cent, salt solu- 
tion, and a cover-slip applied ; or if liquid, various drops are to be 
examined. The different constituents found will vary with the food 
taken as well as with disease. 

A. Constituents Deeived from Food. There may be portions 
of digested or undigested food. In general it may be said that the 
presence of large pieces of unchanged food, or many small particles of 
undigested or only partially digested food, indicates defective digestion 
in the stomach or small intestine. If unchanged bile is present, some 
particles will be colored yellow, another indication of disordered func- 
tion. 

From the food we may see muscle and elastic fibres, more or less, 
according to the quantity of meat eaten by the patient. The former 
are recognized by their transverse striation ; the latter, by their double 
contour and curling ends. Fat may be present as fatty globules or 
in the form of needles, fatty crystals. Much fatty food increases 
their number, and they are seen plentifully in alcoholic poisoning, 
in jaundice, in pancreatic diseases, tuberculosis of intestines, diseases 
of the mesenteric glands, and enteritis. The crystals may be trans- 

FlG. 197. 




Collective view of the feces. (Eye-piece III., objective 8A, Reichert.) a. Muscle-fibres, b. Con- 
nective tissue, c. Epithelium, d. White blood-corpuscles, e. Spiral cells, f-i. Various vegetable 
cells, k. Triple phosphate crystals in a mass of various micro-organisms. I. Diatoms. (Von 
Jaksch.) 



formed into fat-drops by the addition of acid and heat. When meat 
is eaten freely, areolar tissue may be present, but its presence otherwise 
points to defective digestion. Various forms of vegetable cells are 
commonly seen, in which granules of starch may be contained, or the 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 829 

starch particle may be free. Undigested milk occurs in the stools of 
children and when diarrhoea prevails ; a substance, probably casein, 
has been described by Notlmagel as occurring in the feces of persons 
who have intestinal disturbances. 

In persons living on vegetables most of the above constituents will 
be absent, and in infants who partake only of milk, the derivatives of 
meat are absent, while there will be an excess of fatty crystals and fat- 
globules and coagulated products. 

B. Constituents from the Alimentary Tract. Epithelium. In 
every normal stool will be found epithelium of the squamous variety. 

Occasionally the columnar form is seen, and modified epithelial cells 
are very common. In intestinal catarrh their number is greatly in- 
creased. 

Bed Blood-corpuscles. In the majority of blood-stained stools red 
blood-cells are not found ; in their stead will be seen masses of free 
blood-coloring matter and rhombic crystals of hseniatoidin. Red cells 
are seen in dysenteries, in bloody stools in which the blood conies from 
near the anus, as in hemorrhoids, and when blood is discharged with 
the feces soon after the occurrence of the bleeding. If there is any 
doubt as to the presence of blood, when the corpuscle cannot be found, 
a true decision can be reached by examining for hamiin-crystals, ac- 
cording to Teichmann's method. A portion of feces is dried and pow- 
dered, placed on a slide with a grain of common salt, and covered by 
a cover-slip. A few drops of glacial acetic acid are directed beneath 
the slip, the slide is heated just to boiling, and if blood has been pres- 
ent, reddish-brown rhombic crystals of hsemin will soon be found. 

Leucocytes. Leucocytes are frequently seen in healthy stools. When 
pus is present or discharged into the intestinal canal they are found in 
great numbers, as in ulceration of the intestine and in abscess. 

Molecular debris, or detritus, occurs in all feces as part of the waste- 
products. 

Crystals, i^a^-crystals are the most important. They have been 
quite fully considered above. There seems to be little doubt that the 
crystalline needles found in the feces are salts and fatty acids, and not 
ty rosin. 

Char cot-Ley den crystals, similar to those already described (see Spu- 
tum), have occasionally been met with in the stools of typhoid fever 
patients, in dysentery, intestinal tuberculosis, and ankylostomiasis. 

JLazmato idin-cry stals occur as reddish-brown, hard, needle-shaped 
bodies, usually in clusters, and free or enclosed in masses of mucin or 
a substance resembling it. They have been found in the feces of 
breast-fed infants, in cases of chronic intestinal catarrh, and, by Yon 
Jaksch, in the stools of a case of nephritis. 

Crystals of various salts of calcium, of triple phosphate and cholesterin 
will often be recognized, but they have no diagnostic value. When 
bismuth is being administered, black rhombic crystals of the sulphide 
of bismuth will be recognized. 

C. Parasites. (A) Animal and (B) vegetable parasites flourish in 
the intestinal tract, and the presence of some of these in the feces is 
of the greatest clinical importance. 



830 



SPECIAL DIAGNOSIS. 



A. Animal Parasites. Following Leuckart's classification, we 
will consider these parasites under the secondary heads : 

I. Protozoa. 1. Rhizopoda. This variety is made important be- 
cause the amoeba dysenteric or amoeba coli belongs to it. 

(a) Amoeba Dysenterioe. Amoeba Coli. This protozoon has been 
found so many times by various observers in different parts of the 
world that it can now be considered to be the causative factor of so- 
called tropical dysentery. The subject has received special study in 
our own country by Osier/ Stengel, 2 Dock, 3 and Councilman and 
Lafleur. 4 The work of Councilman and Lafleur is at the present time 
the best that has been published in any country ; and to it the reader 
is particularly referred. The following notes are based on this book. 

The amoebae dysenteriae vary in size from 0.012 to 0.035 mm. They 
are found most plentif ally in the small gelatinous masses often to be 
seen in the feces. They vary in number in different cases, and in the 
same case at different times. The severer the lesions the more numer- 
ous are the amoebae. When not active they are round or oblong, and 
highly refractive. They contain one or more vacuoles of varying size. 
Occasionally the division into an ectosarc and endosarc is easily made 
out. When thus inactive they may be confounded with swollen con- 
nective-tissue cells and compound granular bodies found in feces. The 
active amoebae have, however, a characteristic movement. This consists 
of progression and of thrusting-out and retraction of pseudopodia. Their 
activity varies greatly. It is best seen when the body-heat is main- 
tained. The stools should be passed into a clean and warm pan, and 
examined immediately, or kept warm until examined, and a warm 

Fig. 198. 




Amoeba coli. (Hallopeau. 



stage should be used with the microscope. The division into ectosarc 
and endosarc is usually clear during activity. The ectosarc is com- 
posed of a hyaline homogeneous mass, as are the pseudopodia, while the 



1 Johns Hopkins Hospital Bulletin, May, 1890, vol. i., No. 5. 

J Phila. Med. News, 1890. 3 Texas Med. Journal, April, 1891. 

' Johns Hopkins Hospital Reports, vol. ii., Nos. 7, 8, 9. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 831 

endosarc is made up, not of granular matter, but of a dense homo- 
geneous mass enclosing vacuoles and a nucleus. The vacuoles may 
vary in size as well as in number. There may be one or two large 
ones, or the entire endosarc may appear as made up entirely of small 
vacuoles. The nucleus is sometimes plainly seen as a small rounded 
body, but is more often difficult to distinguish from the vacuoles. 
Dried cover-slip preparations may be stained with the various aniline 
dyes, but the results are not satisfactory. 

The amoebae will often be found to enclose bodies such as red blood- 
corpuscles, pus-cells, blood-coloring matter, bacilli and micrococci. 

In examining the feces for amoebse dysenterise the suggestion given 
above concerning the warm bed-pan and warm stage to the microscope, 
and, above all, the immediate examination of the stool, should be ad- 
hered to. The small gelatinous masses should be selected when present. 
Various magnifying powers should be used, including the y 1 ^ oil-immer- 
sion lens. 

(6) Monadines, pear-shaped, with a long slender process, are seen 
alive in only perfectly fresh stools. They are not found constantly in 
any one disease. 

2. Sporozoa. Under this head belongs the coccidium perforans of 
Leuckart. They are short, elliptical bodies, which infest the intesti- 
nal mucous membrane, and may damage it badly; they are often dis- 
charged in large numbers. 

3. Infusoria, (a) Cercomonas Intestinalis. This is a pear-shaped 
body, nucleated, with eight tentacles of varying length. It is found 
in the feces of persons suffering from various diseases, as cholera and 
typhoid fever, and probably of itself causes diarrhoea. 

(6) Trichomonas intestinalis. Larger than the cercomonas, and cov- 
ered with cilise at the club end. It is not diagnostic and is not 
common. 

(c) Paramoecium coli. Larger than the preceding, 1 mm. long — 
oval, covered everywhere with cilise ; may be found in diarrhoeic stools. 

II. Vermes. These are much more generally known and are of 
much more clinical value than the preceding. 

They have important clinical value, as the presence of some of them 
in the intestinal canal gives rise to many untoward symptoms. They 
will be considered under (A) Platodes and (B) Annelides. 

A. Platodes. 1. Tapeworm — Cestodes. These parasites infest 
the small intestine only, to the walls of which they cling by the head. 
The head and neck are small ; the joints are flat and form long ribbons. 
The distal joints continually drop off and can easily be recognized in 
the stools by the naked eye, and the eggs by the use of the micro- 
scope. The feces are best washed in water and broken up to obtain 
the eggs. As the lower joints are lost new ones take their place from 
above. The more important are as follows : 

a. Taenia solium (Fig. 199) reaches a length of two to three metres. 
The head is the size of a pin-head. The neck is 2.5 cm. long, as thick 
as a thread, and without joints. The segments forming the body are 
short and broad near the neck, but as they increase in size there is 
more growth in length than in width. The average dimensions are 9 



832 SPECIAL DIAGNOSIS. 

to 10 mm. by 6 or 7 mm. The head appears dark, the body white. 
The joints are easily detected in the feces by the naked eye. Under 
the microscope the head is seen to be spheroidal, with four pigmented 
sucking-disks surrounding at the base a rostellum, which is a " crown 
of hooks " — chitin hooks — about twenty-four in number. In the ripe 
segments, or proglottides, is seen the longitudinal uterus with about 
twelve horizontal ramifications to a segment. The eggs are round or 
oval, 0.035 mm. long, with a thick, striated shell when ripe, and con- 
tain hooklets. 

Fig. 199. Fig. 200. 






Ova of T. solium, a, with yolk, b, without 
yolk, as in mature segments. The hard Drown 
Head of T. solium. X 45. (Leuckart.) shell is indicated. (Leuckart.) 

b. Tcenia mediocanellata, or saginata. This worm is four or five 
metres long. The head is slightly larger than that of the T. solium, 
and more pigmented, and the segments are longer, fatter, and darker. 
The head is supplied with four powerful sucking-cups, but has no 
rostellum or hooklets. The uterus in the ripe segment is much more 
finely branched than in the solium, and these segments have indepen- 
dent movement. The eggs are very similar to those of the T. solium, 
but may be rather larger. 

c. Tamia nana. In length the T. nana is only 10 to 15 mm., and 
0.5 mm. in breadth. The round head is but 0.3 mm. in diameter. 
The segments are all short, and at the lower end of the body are four 
times as wide as they are long. The head is found to have four round 
suckers at the base of a rostellum that can be inverted. At the base 
of the rostellum are about twenty-two hooklets. The uterus is oblong 
and filled with eggs. The eggs have a double membrane. 

d. Tcenm cucumerina. This parasite is found to be 5 to 20 cm. 
long and about 2 mm. wide. The head is placed at the thinner end, 
and under the microscope are to be seen some sixty hooklets regularly 
distributed about the rostellum, and four sucking-cups. The lower 
segments are decidedly larger than the upper — 6 by 7 mm. When 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 833 

ripe they become reddish, and contain cocoon-like bodies, in which 
are six to twelve eggs. 

e. Bothriocephalus latus. This is the largest of the worms, meas- 
uring 7 or 8 metres. The head is somewhat drawn out, and on either 
side is a long, narrow sucker. There are neither hooks nor rostellum. 
The proglottides are short near the head, but become square further 
down. The uterus appears as a rosette, peculiar to this worm. The 
eggs are oval, and measure 7 mm. by 0.045 mm., have a shell covering, 
with an opening like a lid at one end. Ripe segments are thrown off 
in bunches, not singly. 

It will not be necessary to describe certain other varieties that are 
rarely met with. 

2. Trematodes, or flukes, a. Distoma hepaticum measures 28 mm. 
by 10 mm., and is shaped like a leaf. A short head is situated at the 
broad end and has one sucker ; on the under surface is another sucker, 
and between the two is the opening of the uterus, a highly convoluted 
arrangement. The eggs are brown, oval, about 0.12 mm. long, and 
have a lid at one end. It is not often seen. 

b. Distoma lanceolatum. This round-shaped worm is about 8 mm. 
long and 3 mm. broad, and in other respects resembles the preceding. 
The eggs are more rounded and contain minute embryos. Like the 
D. hepaticum, it is rarely seen. 

c. Distoma crassum is the largest — 4 to 8 cm. long. These flukes 
are endemic in parts of Japan. In general these animals occupy the 
bile-passages or upper part of the small intestine. 

B. Annelides. 1. Round Worms — Nematodes. A. Ascarides. a. 
Ascaris lumbricoides. This is the parasite usually referred to by the 
term round worm. It resembles the common earth-worm in shape 
and color. The male worm is about 250 mm. long, and the female 
400 mm. The head is made up of three prominent lips, and is sup- 
plied with microscopical teeth. The vulva of the female is in the pos- 
terior third of the body. The eggs are rounded, brownish, 0.06 mm. 
in diameter, and covered, when fresh, by a rough albuminous coat over 
a hard shell. This worm has the small intestine for its habitat. It 
may pass with the stools or work its way into the stomach and be 
vomited (the writer has had them thus vomited during the etherization 
of a child of ten years). They have been the cause of jaundice by 
crawling into the ductus choledochus, and may infest the larger hepatic 
ducts. Enormous numbers may be present in the intestine at one 
time. 

b. Oxyuris vermicularis. The thread- worm, or seat- worm, inhabits 
the large intestine, and is often present in the stool as a white, thread- 
like body ; the male 5 mm. and the female 10 mm. long They often 
wander out of the anus and into the vagina. The head has a number 
of small lips, and is covered with a thick skin. The female has one 
vagina and two uteri. The eggs are unsymmetrical, have a laminated 
shell and a diameter of about 4 mm. 

B. Strongylides. Ankylostomum duodenale. This is a round worm, 
reaching a length of 6 to 10 mm. in the male and 10 to 18 mm. in 
the female, and can, therefore, be seen easily, though the eggs are 

53 



834 SPECIAL DIAGNOSIS. 

much more frequently found in the stool than is the worm itself. With 
the eggs there may be present in the stools large numbers of Charcot- 
Leyden crystals. The head is prominent, especially in the male. Four 
hook-like teeth surround the mouth, and by these the animal attaches 
itself to the intestinal wall. The tail of the male is expanded and that 
of the female pointed. The vulva is in the posterior third. The eggs 
are oval, about 0.05 mm. in diameter, and contain one to four cells — 
embryonic globules, which rapidly develop in a warm place outside 
the body, and may thus be recognized. The worm infests the small 
intestine, especially the jejunum. It often causes serious symptoms — 
bloody stools and intense anaemia. 

c. Trichotrachelides. a. Tricocephalus dispar. The whip- worm is 
4 to 5 cm. in length, the female being longer than the male. It is 
recognized by the contrasting form of the anterior and posterior por- 
tions. The former is thin and threadlike, the latter expanded and 
broad, and in the male curled up. The eggs are brownish, about 0.05 
mm. long and half as broad, and have a button-like projection at either 
end ; they are to be recognized in the stools, where large ones may be 
present. There may be only a few or thousands of the forms present 
in the body. They live chiefly in the caecum and large intestine. 
They have been thought to cause beri-beri by some writers. 

b. Trichina spiralis. It is the adult trichinae which exist in the 
intestine and are found very infrequently in the feces. These produce 
the embryos, which become muscle trichinae. The adult male is 1.5 
mm. long and the female twice that length. The former has two pro- 
jections from the hinder end, between which are four papillae. The 
female has a tubular uterus and a tubular ovary in the posterior half 
of the body. 

D. Rhabdonema. Strongylides. Under rhabdonema intestinale 
we now include two small nematodes, which were termed anguillula 
intestinal] s and A. stercoralis, and which are probably one and the 
same. They are found in the stools of cases of endemic diarrhoea of 
hot countries. Usually the young embryos, which have developed in 
the intestinal canal, are dejected with the stools. These sexually 
mature embryos are 0.8 to 1.2 mm long, male and female respectively. 
They are round and have a cone-shaped head. There are two jaws 
and two teeth in each. The adult worm is about 2.2 mm. long and 
0.04 mm. thick. The mouth has three lips. The vulva is at the be- 
ginning of the posterior third. The eggs might be easily confounded 
with those of the ankylostomum duodenale, but are somewhat more 
pointed, and larger. The rhabdonema infests the small intestine, and 
is frequently found in connection with ankylostoma. 

Echinococcus hooklets and portions of the striated cyst-wall have 
been found in the feces. The rupture of a hydatid cyst into the in- 
testine may be discovered when the above structures are found, point- 
ing to a cyst in the abdominal cavity. 

B. Vegetable Parasites. We find both (I) pathogenic and 
(II) non-pathogenic vegetable parasites in the feces. The latter we 
have classed as (1) moulds, (2) yeasts, and (3) fission-fungi. 

1. Moulds. The only mould found in the stools is the thrush 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 835 

fungus, when children are the subjects of thrush in the mouth. It is 
of very rare occurrence in the feces, and has no special clinical import. 

2. Yeasts. In all feces, in health or disease, yeast fungi exist. 
They are most numerous in acid stools. They are round or ovoid, and 
usually occur in groups. They stain dark broAvn with a solution of 
iodine and iodide of potash, while apparently similar cells become 
violet or blue with the same dye. 

3. Fission-fungi. Bacteria are found in greatest numbers in the 
feces, chiefly as bacilli, micrococci, and spirilla. They may be grouped 
as torulse or sarcinse. They present active movement, and may be 
separate or in colonies. The bacillus coli communis (B. termo) is the 
most frequent form met with, both in health and disease. It is not 
yet determined what relations it holds to normal and abnormal condi- 
tions, or what is the true relationship between it and certain other bac- 
teria. B. subtilis is another bacterium found both in health and 
disease. As above stated, there are various organisms which stain 
brown Avith iodo-potassic-iodide solution, and others which become 
blue with the same dye. Yon Jaksch has studied these latter closely. 
They take various forms, as long or short rods, and take different 
shades of blue or violet. One of them is the Clostridium butyricum 
of Nothnagel. It occurs as large round cells, like yeast fungi, and 
stains like the tubercle bacilli with the Ziehl-Neelsen fluid. Von 
Jaksch finds these fungi in greater abundance in intestinal catarrh. 
They are present in both acid and alkaline stools. 

Bacillus coli communis has been found in the blood, various 
organs, feces of cholera patients, in healthy feces, in the air, and in 
putrefying infusions ; it can also be found in the peritoneal exudate 
in most cases of peritonitis. 

3forphology. A bacillus, 4 to 6// by 2 to Z/u, with rounded ends, 
sometimes in cultures a short oval. Five or more flagella have been 
observed attached to the organism. 

Biological Properties. Aerobic ; facultative anaerobic ; non-liquefy- 
ing ; slightly non-motile. 

Growth. On gelatin plates the colonies vary very much. The deep 
colonies are transparent, straw color to dark brown, or may be granu- 
lar and opaque. The surface-colonies are large and spherical, centre 
dark brown, edges transparent. In stab-cultures the surface-growth 
is thin and dry. There is abundant growth along punctures, which 
is white by reflected, but amber by transmitted light ; sometimes 
moss-like tufts are seen. On potato a soft, shining, brownish-yellow 
layer grows. Stains with anilines, but not by Gram's method. In- 
jected in guinea-pigs it produces fever, diarrhoea, and collapse. In- 
jected into the abdomen of rabbits it causes a typical peritonitis. 

Pathogenic Fungi. Spirillum Choler.e Asiatics. See page 
338. 

Spirillum Cholera Nostras. Morphology. Longer and thicker 
than the spirillum of Asiatic cholera ; central part thicker than ends. 
Stains as the true cholera spirillum. 

Biological Properties. Culture. A thick, stocking-like funnel of 
liquefaction instead of a fine, straight funnel. (See Fig. 87, page 340.) 



836 SPECIAL DIAGNOSIS. 

Typhoid Fever Bacillus. This bacillus is present in the stools 
of typhoid fever patients, but cannot be directly differentiated by 
microscopic examination alone, either when stained or unstained. It 
is necessary for its detection to make pure cultures according to bac- 
teriological methods. The bacillus is about as long as the tubercle 
bacillus, but much thicker, being one-third as thick as it is long. 
The ends are rounded. It is best stained by concentrated aqueous 
solutions of methylene-blue, the dried preparations on the cover-slip 
being prepared as above. (See Plate III., Fig. 6, b ; and Typhoid 
Fever). 

Tubercle Bacillus. The bacillus of tuberculosis is frequently 
found in the feces of persons suffering from intestinal tuberculosis and 
occasionally in the feces of cases of pulmonary tuberculosis, when 
sputum has been swallowed. When tubercle bacilli are constantly 
found in the feces, and in large quantities, ifc points to the former 
condition almost to a certainty. They are detected by methods em- 
ployed in the examination of sputum. 

Bacilli op Booker. No less than nine bacilli have been described 
by Booker. They have been found by him in cases of diarrhoea in 
children. Seven of them resemble very closely the bacillus coli com- 
munis. Bacillus A is a bacillus with rounded ends, 3-4/z by 0.7 fi. 
It is aerobic and facultative anaerobic, liquefying, and motile. Colo- 
nies on agar and potato are dirty brown. On gelatin they liquefy too 
soon to show characteristic form. The bacillus is found in the stools 
of cholera infantum. 

Chemical Examination. The chemical examination of the feces 
is of but slight clinical value. Mucin and albumin are normally pres- 
ent ; peptones in different diseases (Von Jaksch). Among the acids 
to be found are bile-acids, volatile and fatty acids, formic, acetic, 
butyric, and propionic acids ; while phenol, indol, skatol, cholesterin, 
and fats are always present, according to the same author. They will 
not aid in diagnosis. 

The normal coloring-matter of the feces is urobilin ; its presence is 
shown by the proper tests. As before stated, bile-pigment never 
occurs in the feces in health ; it is present when there is catarrh of the 
small intestine. Blood-pigment is usually in the form of hasmatin. 
As might be expected, ptomaines have been obtained from the feces 
of certain diseases caused by fungi. 

Diseases Characterized by Pain and Flatulence. 

Intestinal Indigestion. Intestinal indigestion is said to be due to 
alterations in or diminution of the bile, the pancreatic, or the intestinal 
secretion. It is almost always attended by gastric indigestion, and 
may not readily be distinguished from it. 

Acute Intestinal Indigestion. Acute intestinal indigestion is 
due to the irritation of food not properly digested in the stomach. It 
is attended with colic, flatulency, and borborygmi. Some fever may 
develop, and diarrhoea may ensue. In the mild forms the tongue is 
coated, there are loss of appetite and some general pains. There is 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 837 

epigastric distress or pain in the right upper quadrant. Flatulency 
and constipation occur. The stools are often clay-colored 7 or may 
not be changed. Slight jaundice occurs, and there is an abundance of 
lithates in the urine. Accompanying gastric indigestion modifies the 
symptoms slightly. 

The symptoms are more marked and pronounced in chronic intestinal 
indigestion. The local symptoms are as follows : Pain which begins 
from two to six hours after eating. It may be complained of in the 
region of the liver or below the sternum. It is usually seated in the 
umbilical region. It is dull and continues two or three hours, or until 
the next meal is taken. There is some tenderness. With the pain 
there are tympanites, borborygmi, and a sense of fulness in the abdo- 
men ; the bowels are constipated, and the stools are hard and dry. 
The constipation alternates with diarrhoea, and undigested particles of 
food are passed. The appetite is not lost, but is variable. Hemor- 
rhoids are often present. 

The general symptoms are marked, and are referred to the nervous 
system and the condition of the blood. There are great depression and 
hypochondriasis. The patients sleep badly, suffer from bad dreams and 
tinnitus aurium ; there are spots before the eyes and more or less constant 
headache. They complain of pain in the back and limbs, and hyper- 
esthesia and anaesthesia are present. There is inaptitude for mental 
exertion. Frequently the patient has sudden attacks, apparently due 
to toxins, as sudden fainting followed by collapse, or vertigo. During 
these attacks there are great palpitation and tachycardia. The ex- 
tremities are cold, and there are cold sweats over the body. Inde- 
pendently of the attacks, the patient is subject to palpitation and some 
dyspnoea. The urine is always high-colored, acid in reaction, and full 
of urates and uric acid. Oxalate of lime may be present, and the 
albuminuria of uric acid occurs, due to the irritation. The patient 
early becomes anaemic, because of the auto-intoxication and poor 
assimilation. There is some emaciation ; in some cases the emaciation 
is rapid. The complexion is sallow. If there is an abundance of 
oxalates, the patient complains of weight and heaviness about the loins. 
The stools may contain fat, indicating probable pancreatic disease, if 
fatty food has been ingested. On the other hand, with loss of appetite, 
furred tongue, frontal headache, and drowsiness, the stools may be 
clay-colored and the bowels costive ; apparently the bile is at fault. 

Diseases Characterized by Pain and Diarrhoea. 

Acute Intestinal Catarrh. Cause. Exposure to cold or the direct 
irritation of mechanical or chemical substances within the intestine. 
Irritating food that is not digested, or that cannot be digested because 
of the quantity ; spoiled meats and unripe fruit usually excite an 
attack. Water saturated with impurities, or such as the individual is 
not accustomed to, may excite an attack. Strangers in a new locality 
are frequently subject to a diarrhoea until accustomed to the drinking- 
water, which in the native does not excite catarrh. Toxic substances, 
as poisons or drags, or toxic substances the result of putrefaction, as 



838 SPECIAL DIAGNOSIS. 

ptomaines, are frequent exciting causes. Extension of inflammation 
from neighboring structures by infection, as in peritonitis, sets up a 
catarrh. Local diseases of the intestine, as ileus, intussusception, her- 
nia, and ulcers of all forms, are attended by catarrh of the intestine. 
It also occurs in cachectic states of the system, as cancer, anaemia, and 
Bright' s disease. In disease of the heart and bloodvessels, or of the 
liver and spleen, where the disturbance of the circulation causes a con- 
gestion, catarrhal inflammation occurs. It is of common occurrence 
in the infectious diseases, and particularly in septicaemia and pyaemia. 

Symptoms. Diarrhoea is the chief symptom, varying with the cause 
and the extent of the catarrhal inflammation. The stools differ in fre- 
quency and in color, as has been previously indicated in the various 
types. They contain undigested matter ; sometimes worms. Colicky 
pains about the umbilicus, with borborygmi and frequent desire to go 
to stool, attend each evacuation. The fever is of the remittent type, 
and is attended with some prostration. The urine is scanty and high- 
colored. The symptoms vary somewhat with the location of the in- 
flammation, although the exact locality cannot be distinctly defined. 
The symptoms of proctitis, pain with tormina and tenesmus, do, how- 
ever, enable the localization to be made to that portion of the bowel. 
These are more common than in inflammation apparently limited to 
the small intestine, Avhile in colitis the violence of the rectal symptoms 
stands between enteritis and proctitis. 

The diagnosis of acute intestinal catarrh is not difficult. It is more 
difficult to determine the actual cause. If the attack occurs suddenly 
after the eating of improper food, or the drinking of impure water, the 
irritation is probably due to that cause, and may be determined by the 
nature of the feces. If they contain undigested food, the diarrhoea is 
probably due to indigestion. Catarrh from cold usually follows ex- 
posure, and is generally not very severe. To estimate the cause from 
poison or drugs the condition of the rest of the intestinal tract must be 
investigated and other symptoms of the effects of drugs must be in- 
quired for. In arsenical poisoning there is always vomiting and the 
discharges are of a choleraic nature. Collapse rapidly ensues. The 
other symptoms of arsenical poisoning must be inquired for and the 
history of exposure, if possible, ascertained. The intestinal catarrh 
due to infectious diseases is attended by the symptoms due to the 
respective affections, each of which is usually readily recognized. It 
may be necessary to resort to a bacteriological examination of the feces. 
The intestinal catarrh which occurs on account of local disease of the 
bowel, as hernia, stricture, etc., is preceded or attended by the local 
symptoms of these diseases. In like manner we judge of the nature 
of the diarrhoea that occurs in the course of tuberculosis or syphilis, 
and in the course of organic heart disease or of liver disease. In each 
instance the possible influence of morbid processes present in other 
structures must be very carefully estimated. 

The Varieties of Acute Intestinal Catarrh. Divisions 
have been made in accordance with the symptoms which distinguish 
the various localities of the intestine in which the inflammation is most 
marked. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 839 

Catarrh of the Duodenum. This partakes of the nature and has the 
symptoms of gastro-intestinal catarrh in a mild degree, and is charac- 
terized by the occurrence of jaundice due to catarrhal inflammation of 
the biliary passages. 

The Small Intestine. Colicky pains and rumbling are experienced. 
There is usually gastritis at the same time. The feces are mixed with 
mucus. Over the right lower quadrant there is tenderness on pressure. 

Caecum. Pain in the right lower quadrant with tumor, dulness on 
percussion, and tenderness are present. (See Typhlitis.) 

Colitis. The large intestine is most frequently affected. Pain and 
tenderness occur along the course of the bowel. The evacuations 
contain mucus ; there is tenesmus. The association with gastro- 
enteroptosis and with neurasthenia must be borne in mind. 

The Rectum. Proctitis gives rise frequently to small stools, tenes- 
mus, pain in the left lower quadrant, with tenderness about the anus, 
and spasms of the sphincter. There are considerable mucus and blood 
in the passages. 

Cholera Infantum. This affection occurs in children during the 
hot season. It is promoted by bad hygienic surroundings, and is due 
to improper milk or food. At first there is catarrhal diarrhoea. This 
may continue for twenty-four hours, then vomiting and diarrhoea 
ensue. The stools are liquid and large in amount. At first they may 
contain milk-curds. The vomiting is excited by anything taken into 
the mouth, or by odors, or by movement of the little patient. The 
watery discharges are almost constant. They may be preceded by 
greenish or yellowish-green stools for twenty-four hours. Stools are 
acid in reaction, and their odor is sour. At first there is colicky pain, 
but when the watery discharges begin there is only a little tenesmus. 
The stools irritate the skin and cause eczema. The rectum may be- 
come prolapsed. The abdomen is at first distended with gas, but soon 
becomes retracted. 

In a short time, twenty-four hours or even less, collapse ensues. 
Previous to the collapse the skin is hot and dry ; the patient is restless. 
The thirst is intense, the mouth dry. The body-temperature is 103° to 
104°. With collapse the extremities become cold, the skin cool. The 
axillary temperature is lowered and the rectal temperature increased to 
105° to 106°. The restlessness continues, the fontanelles become de- 
pressed, the eyes sunken, the face pinched, the brows drawn. The urine 
diminishes in amount or may disappear entirely. Brain symptoms 
ensue. So-called hydrocephaloid symptoms follow — rolling of the head, 
strabismus, turning in of the thumbs, and, later, convulsions. Stupor 
followed by coma develops in the fatal cases. If the patient does not 
die in collapse, marasmus develops ; ulceration of the cornea may take 
place ; there are oedema and blood extravasation under the skin. The 
child emaciates and withers. On account of the weak heart and ex- 
haustion pulmonary atelectasis or bronchopneumonia may occur. The 
age, the season, the presence of catarrh, with collapse and other symp- 
toms, render the diagnosis easy. 

Cholera Morbus. The attack is characterized by sudden vomiting, 
followed in a short time by purging. The vomiting may be preceded 



840 SPECIAL DIAGNOSIS. 

by pain, or both may occur at the same time. At first the pain is 
seated in the epigastrium and subsequently about the navel. It is 
very severe and paroxysmal in character, compelling the patient to 
double up if lying in bed. A cold perspiration breaks out on the fore- 
head, the extremities become cold, the face anxious ; the pulse becomes 
rapid. At first the patient vomits undigested food, then watery, 
greenish-colored fluid. The latter is bitter. Purging sets in at once, 
or within an hour. The bowel-movements follow an attack of pain. 
The first passage is fecal, and may contain undigested food ; the subse- 
quent passages are watery and profuse. There are severe attacks of 
burning and tenesmus ; the abdomen is tender around the navel and 
in the epigastrium. After an evacuation there is slight relief, but soon 
another paroxysm of pain comes on. The vomiting is excessive, and 
retching may be present in the intervals. Ice, or water, or anything 
taken into the stomach excites pain and causes the vomiting. The 
attack subsides in twelve to twenty-four hours, and is followed by ex- 
haustion. In rare cases collapse ensues, and in others it is followed 
by gastro-intestinal catarrh. 

Cholera Nostras. The symptoms are those of severe gastro-enter- 
itis. There are sudden vomiting and diarrhoea. It usually begins in 
the night. The vomiting is not different from that of cholera morbus. 
The watery and brownish-colored stools become colorless and have the 
appearance of rice-water. Pain attends the attack, rapid prostration 
ensues, the extremities become cold, and collapse takes place. With 
the collapse there are cramps in the legs. Other muscles of the body 
may become cramped. The disease occurs in epidemics during the hot 
season, and may be mistaken for cholera. It can be distinguished from 
the milder forms of cholera which precede the occurrence of the epi- 
demic only by the absence of the comma-bacillus. The bacillus of 
cholera nostras is found in the stools. (See Feces.) 

Entero-colitis. In entero-colitis the more intense inflammation 
succeeds a mild intestinal catarrh. There are increased languor, great 
fretfulness, and fever. The early catarrh is attended by green acid 
stools, with lumps of casein. The tongue is furred and moist at first. It 
soon becomes red and dry ; vomiting ensues. The stools are offensive 
and increase in frequency, and, in addition to the appearance first indi- 
cated, contain mucus and blood. Death may take place within the 
first week, on account of exhaustion from the vomiting and diarrhoea. 

If the disease is protracted, it is attended by great wasting, symp- 
toms of hydrocephalus, skin eruptions, hypostatic pneumonia, and ex- 
tremely weak, feeble circulation. 

Chronic Intestinal Catarrh. It usually follows an acute attack, or 
may be chronic from the start. It may follow gastric hyperacid- 
ity and dilatation of the stomach. It arises secondarily to portal con- 
gestion in disease of the liver and in chronic disease of the heart or of 
the lungs. It occur in malaria and in the scorbutic cachexia. 

The symptom is diarrhoea alternating with constipation, or diarrhoea 
alone. Stools may contain undigested food, or pus, mucus, and blood 
in small amounts. Diarrhoea may be present in the morning only 
under these circumstances. If the feces are examined, the eggs of 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 841 

parasites, or infusoria may be found. The local abdominal symp- 
toms of rumbling, flatulency, and tormina are present. There are 
reflex symptoms of cardiac palpitation and dyspnoea (asthma). Rush 
of blood to the head may occur. Often these symptoms are relieved 
by the passage of flatus. Chronic catarrhal gastritis usually accom- 
panies the intestinal catarrh. The general symptoms of anosmia y 
emaciation, and neurasthenia are present. Hemorrhoids are common. 

Amyloid Degeneration of the Intestines. The symptoms are 
those of diarrhoea, persistent but mild in character, associated with 
symptoms of amyloid disease in other organs. With enlargement of 
the liver and spleen changes in the urine due to amyloid disease are 
present. The occurrence of these symptoms in a patient with syphilis, 
or especially in a child with bone disease or tuberculosis, points to the 
nature of the case. 

Ulceration of the Intestines. Duodenal Ulcer. Ulcer of the 
duodenum usually occurs in young subjects in whom there are symp- 
toms of chlorosis or anaemia. The causes are the same as those of 
gastric ulcer. It may follow boils, erysipelas, or pemphigus, and 
differs in one etiological respect from ulcer of the stomach, in that it 
occurs more frequently in the male sex. The symptoms are obscure, 
and may be wanting entirely, the patient probably complaining only 
of intestinal indigestion. In other cases they are like those of gastric 
ulcer. In typical cases the symptoms are those of pain situated below 
the xiphoid or to the right of the median line in the region of the 
pylorus. The pain occurs after eating, and may be relieved by vomit- 
ing. There is localized tenderness on pressure. Hemorrhage may 
take place from the stomach, or blood be found in the stools alone. It 
differs from gastric ulcer only in the possible difference in location of 
the pain, the occurrence of intestinal indigestion and hemorrhage, and 
the fact that the pain comes on one to two hours after eating. 

Duodenal ulcer is diagnosticated by the occurrence of melsena, which 
may be excessive and cause syncope and vomiting with no blood in the 
vomitus ; by pain, which may be in the right hypochondrium or be- 
tween the navel and the right costal border ; by gastralgic attacks ; by 
dyspepsia, with constipation. 

General Ulceration. Ulceration of the intestine may be due 
to a specific infection, and hence be symptomatic of typhoid fever, 
syphilis, and tuberculosis. It is always present in the first mentioned, 
and of frequent occurrence in the latter. Follicular ulceration occurs 
in entero-colitis in children. Ulcers due to the pressure of feces occur 
in typhlitis and chronic constipation. The sacculi of the colon become 
filled with scybalous masses, the pressure of which produces ulcers. 
Tenderness is experienced along the course of the colon, particularly 
on palpation of the fecal masses, which may be felt through the 
abdominal wall. A chronic ulcerative colitis is the form that succeeds 
the diarrhoeas which occur during camp-life, or that are set up in com- 
munities where people are crowded and live under bad hygienic cir- 
cumstances. It is the form that attends scurvy, and is frequently seen 
in chronic Bright' s disease. It may be succeeded by dilatation of the 
colon, by hypertrophy of the muscular walls, or by contraction of the 



842 SPECIAL DIAGNOSIS. 

bowel. The persistent diarrhoea leads to profound emaciation, extreme 
prostration, sallow complexion, with markedly impaired nutrition of 
the skin. Such forms of diarrhoea were seen during the late war, par- 
ticularly in soldiers held in captivity. The diarrhoea may first be of a 
lienteric character, and later alternate with constipation. Stools con- 
tain blood and mucus. 

Ulcers of the intestinal tract may occur from other causes, and diar- 
rhoea may be the predominant symptom. They may be due to cancer ; 
the malignant nodules may ulcerate within the lumen of the bowel. 
The bowel may be perforated from the exterior, on account of suppura- 
tion somewhere along its course, as in appendicitis, pancreatitis, or 
tuberculous peritonitis. 

Symptoms. The symptoms of intestinal ulcer are usually those of 
diarrhoea. Ulceration, however, may be present without any symp- 
toms whatsoever, particularly if the small intestine is affected. One 
or two small ulcers, on the other hand, in the lower portion of the 
colon, may set up continuous diarrhoea. The stools are composed of 
feces, mucus, pus. shreds of tissue, and blood. If pus is discharged in 
large amounts, an abscess has probably opened into the bowel. Mod- 
erate discharge of pus usually follows ulcers in the colon. Pus may 
be present in cancer. Hemorrhage is of frequent occurrence, and is an 
important diagnostic symptom, especially if profuse and occurring 
without symptoms of obstruction, of gastric ulcer, or of hemorrhoids. 
The fragments of tissue found in the stools may point to the nature of 
the process. Large amounts attend the dysenteric process. The frag- 
ments may be composed of the mucosa, connective tissue, and the 
muscular coat. Pain occurs in many of the cases. It may be general 
and colicky, or circumscribed in cases of ulcer of the colon. Perfora- 
tion of the intestine is followed by localized or general peritonitis. 
The occurrence of the latter depends largely upon the situation and the 
rapidity of the ulceration. If the perforation is in the posterior wall 
of the colon, a circumscribed abscess may develop. When it is situ- 
ated in the upper zone the pus may accumulate underneath the dia- 
phragm, or in the lesser peritoneal cavity. The signs of pyopneumo- 
thorax subphrenicus occur when the latter accident takes place, as both 
pus and air accumulate in the abscess-cavity. In such instances the 
ulceration usually takes place at the splenic flexure. Perforation of 
an ulcer of the caecum may simulate appendicitis. 

Tuberculosis of the Intestine. The disease is usually secondary 
to chronic tuberculosis, but may be primary, especially in children. 
The symptoms are usually those of diarrhoea, and in the primary form 
this is associated with general emaciation, which advances rapidly, and 
with anaemia. Fever of the intermittent or remittent type is present. 
There is meteorism ; the abdomen is much distended, but eventually 
becomes contracted. The mesenteric glands can be made out along 
the spinal column, and the intestines may become bunched into a mass, 
yielding a dull tympany on percussion in the centre of the abdomen. 
The diarrhoea is attended with colicky pains. The diagnosis is based 
upon the rapid emaciation, irregular fever, enlargement of the mesen- 
teric glands in a patient, usually a child, who had probably been ex- 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 843 

posed to tuberculous infection. In one of my cases, the child, aged 
four years, ate of the same food, using the same utensils, as a brother, 
a young man of twenty-two years, dying of pulmonary tuberculosis. 
The child was constantly with the brother. The remainder of the family, 
eight in number, remained in perfect health, and were all of good 
physique. The elder brother became infected by association with 
tuberculous subjects in improper quarters away from home. 

Intestinal Obstruction. 

Intestinal obstruction may be acute or chronic. Acute obstruction 
may set in in the course of chronic obstruction due to stricture of the 
bowel, to occlusion due to external pressure, or to accumulations within 
the bowel. 

Causes. Acute intestinal obstruction is due, first, to constriction by 
bands or strangulation of the bowel through apertures ; second, to 
volvulus of the colon ; third, to acute intussusception. 

In the first instance the type of the obstruction is seen in strangu- 
lated hernia, but similar strangulations occur in apertures within the 
peritoneal cavity. Thus loops of the intestine are caught and con- 
stricted in the duodeno-jejunal fossa, the so-called Treitz' retro- 
peritoneal hernia, or in the foramen of Winslow, also known as 
inter-sigmoid hernia ; finally, diaphragmatic hernia, in which protru- 
sions of the intestine through the diaphragm, along with other abdominal 
viscera, may take place. The above-mentioned forms of hernia may 
exist without symptoms, or may lead to constriction or twisting of the 
loop of the intestine, with occurrence of acute obstruction. Moreover, 
lacerations in the omentum may give rise to internal constrictions. 
External constrictions, however, take place, most commonly in the 
regions of hernias, on account of the gut being constricted by dense 
fibrous adhesion ; or about the uterus or Fallopian tubes, which had 
previously been the seat of inflammation. The constricting bands 
that follow the local peritonitis may gradually occlude the gut, or be 
in such position that the latter becomes twisted about it. In other 
forms of peritonitis similar constricting bands may form, which are 
liable to produce this accident. Disease about the vermiform ap- 
pendix, with secondary adhesions, has been observed to cause con- 
striction. A frequent form of intestinal obstruction is due to the 
tangling of the intestines in the foetal remains of the omphalomesen- 
teric duct, Meckel's diverticulum, which is situated a short distance 
above the ileo-csecal valve. 

Volvulus is a form of acute obstruction due to twisting or knotting 
of the intestine. The condition is not common. It occurs most fre- 
quently at the sigmoid flexure of the colon. The mesentery of the 
latter is often congenitally narrowed, on account of which the colon is 
unduly dragged upon, and, if filled with masses of feces, cannot restore 
itself ; the twisting becomes permanent, and obstruction takes place. 
Peristalsis is set up and other portions of the intestine wind about 
the pedicle of the loops, so as to form a regular knot. Abnormal 
peristalsis, on account of diarrhoea, often precedes the appearance of 



844 SPECIAL DIAGNOSIS. 

the obstruction. External injury is said also to give rise to the forma- 
tion of an obstruction. 

Intussusception (Plate XXXIX. , Fig. 1), as a cause of intestinal 
obstruction, occurs most frequently in children, and is due to a portion 
of the bowel being pushed into the lumen of that which lies next below 
it. A circumscribed portion of the intestine may be paralyzed. In the 
portion above, the peristaltic action continues and the energetic move- 
ments push it into the paralyzed part. Intussusception is found fre- 
quently after death in the bodies of children dying from exhaustion. 
In such cases it occurs just before death. Intussusception also occurs 
when intestinal polypi drag one portion of the bowel into the lower 
portion. Large portions of the intestine may be involved. The inva- 
gination usually takes place at the lower portion of the ileum, or into 
the caecum ; sometimes the invaginated portion may reach the rectum 
and project externally. Intense inflammation and adhesion are set up. 
The internal portion becomes gangrenous, on account of constriction of 
the afferent vessels. This portion may slough and pass with the dejec- 
tions, followed by spontaneous cure. 

Chronic intestinal obstruction may be due to occlusion by external 
pressure, or by the excessive accumulation of material within the 
bowels, or to stricture. The various causes are specified below. 

Intestinal obstruction, to view it from another stand-point, may be 
due to (a) disease outside of the intestines ; (6) to disease of the intes- 
tinal walls ; (c) to accumulation within the intestine. 

The obstruction takes place under the same circumstances as ob- 
struction in other channels. 

A. Diseases Outside of the Intestines. 1. Pressure of tumors, chiefly 
ovarian tumors, uterine tumors, tumors of the omentum, and pelvic 
abscess, or abscess about the caecum. The obstruction may be acute 
or chronic. The symptoms of obstruction develop gradually, although 
in some instances they may take place suddenly, especially if aided 
by the accidental occurrence of fecal impaction. 

2. Constricting bands, hernial openings, the remains of foetal struc- 
tures, cause constriction of the intestine. In this class of cases there 
is usually pain, and the history preceding the obstruction is that of 
peritonitis, general or local, of old hernia, of appendicitis, of pyosal- 
pinx, or of inflammation about the gall-bladder and gall-ducts. The 
onset may be acute or chronic. If the constriction is due to protrusion 
into hernial openings, the onset is usually sudden and without previous 
symptoms. 

3. Peritonitis is a most common cause of acute intestinal obstruction. 
It may be due to overdistention by gas and paresis of the bowel, or to 
pressure by external exudation. 

4. Knots and twists of the intestines, usually seated about the sig- 
moid flexure, causing volvulus, are a common cause of acute constriction. 

B. Disease of the Intestinal Walls. 1. Invagination, or intussuscep- 
tion. The attack is acute, although the affection may continue over a 
long period of time. 

2. Cancer and other tumors of the intestine generally lead to stric- 
ture and chronic obstruction. 



PLATE XXXIX. 



FIG. 1. 






T 

PerUt v. 



Tumor K 



Invagination of the Ileum. 



FIG, 2. 



\ 



Tumorfk 



Carcinoma of the Colon. 






DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 845 

3. The healing of ulcers, which are syphilitic in the larger number 
of cases, rarely tuberculous, will lead to stricture. The obstruction 
belongs to the chronic variety. It is seated, in the larger number of 
instances, in the rectum or sigmoid flexure of the colon. 

C. Accumulations within the Intestines. 1. Feces. The obstruction 
takes place gradually, occurs in weak and debilitated people in the 
course of constipation, especially the constipation of acute disease. 

2. Accumulations of improper food or foreign materials. The seeds 
of fruits or the husks of grain accumulate and cause obstruction. 
Magnesia, iron, and other articles taken as medicines, from their accu- 
mulation lead to obstruction of the intestine. In both of the above 
mentioned varieties obstruction is chronic. 

3. Impaction of gallstone within the intestine is followed by acute 
obstruction. 

The Symptoms. When symptoms of intestinal obstruction occur 
it is important to ascertain, in addition, first, the duration of the ob- 
struction and its mode of onset ; second, the possible cause of the ob- 
struction ; third, the seat of the obstruction. 

The Symptoms Common to Acute Obstruction. The symptoms of intes- 
tinal obstruction depend upon the nature and the seat of the obstruction. 
Constipation. The major symptom is stoppage of the intestinal contents. 
When this takes place suddenly, and there is a local injury to the 
bowel, the symptoms, both local and general, are severe and alarming. 
When the constipation is complete there is no escape of flatus. Pain. 
The pain is at the seat of obstruction or about the umbilicus. It 
occurs suddenly, and is intense and colicky or lancinating in character, 
radiating from the point of obstruction. There is tenderness over the 
painful part. The pain is due to the injury by the constricting agent 
or to violent peristalsis. It may be relieved by pressure. When inter- 
mittent, the obstruction is incomplete ; when constant, it is absolute. 
Tumor. In many instances a tumor can be outlined due to single loops 
of intestine, thickened walls, or abnormal contents. This is particularly 
the case in the obstruction of invagination and the obstruction due to 
volvulus. Peristalsis. The obstruction further causes increased peri- 
stalsis. This takes place above the point of constriction. Sometimes 
the movements of the intestine can be seen through the abdominal 
walls. The extent of the peristalsis is an indication of the site of the 
obstruction. The higher the obstruction, the less the peristalsis. 
Meteorism. The obstruction causes accumulation of gas above the 
point, giving rise to meteorism. If the obstruction is low down, the 
distention and meteorismus are general. If high up, as in the small 
intestine, on account of constriction by Meckel's diverticulum or inter- 
nal hernia, the meteorism is in the upper part of the abdomen, and 
may be limited in extent, or dilatation of the stomach alone may be 
present. Vomiting. Vomiting soon occurs in acute intestinal obstruc- 
tion, due to decomposition of intestinal contents, to irritation of the 
stomach by the intestinal contents, to a trauma of the peritoneum at 
the seat of the obstruction, or, finally, to the occurrence of peritonitis. 
At first the contents of the stomach are ejected, then watery fluid, bile 
tinged or largely made up of bile, and later feculent matter. Although 



846 SPECIAL DIAGNOSIS. 

of fecal odor, this is not true stercoraceous vomiting ; the latter occurs 
later in the course of the disease. It must not be forgotten that any ob- 
struction of the intestine may develop with extreme rapidity, so that 
fecal vomiting may occur within two hours of the commencement of an 
obstruction. It is recognized by the odor of the matter vomited and 
by its color. It is a grave symptom, indicating complete obstruction 
of the intestine. If the obstruction is high up, as in the jejunum, 
fecal vomiting does not occur. The vomiting, however, is more per- 
sistent in high obstruction. Eructations of gas are frequent. The 
general symptoms are those of extreme prostration or shock in its most 
pronounced form. The abdominal fades previously described develops 
very rapidly. The tongue is not changed at first, but soon becomes 
dry and brown. In a few instances, as in invagination, there may be 
fever, but in other cases usually at once, or very soon in its course, the 
temperature falls to normal or subnormal, or remains at this point if 
it has not risen. The extremities are cold, the features pinched, the 
eyes sunken, the expression anxious. The pain causes the patient to 
double up in bed. The pulse becomes rapid, weak, and thready in 
character. The respirations are proportionately hurried, but are also 
made more rapid and shallow by the tympany. The mind remains 
clear until the supervention of peritonitis and septicaemia. 

The Symptoms Common to Chronic Obstruction. The symptoms are 
those of chronic constipation, with local symptoms due to the cause of 
the obstruction. The bowels are moved infrequently, and then in 
small amounts. In obstruction due to stricture from cancer, or cica- 
tricial closure, the feces are ribbon-shaped. Reference must again be 
made to the occurrence of so-called spurious diarrhoea, with or without 
the passage of small scybalous masses, on account of impaction of feces. 
Some credence can be given to the oft-repeated expression of the pa- 
tients that they have a sense of obstruction in the bowel and that they 
experience great relief when there is a free evacuation. In chronic 
obstruction the general symptoms are those of inanition, with the ner- 
vous train of symptoms that have been described in constipation ; 
while the local symptoms depend upon the cause. When the local 
symptoms are due to the pressure of a tumor, or accumulation of pus 
or fluid within the abdomen, there is a history of local disease, on ac- 
count of which the tumor developed ; such history is obtained in 
fibroids or ovarian tumor, or in previous inflammation, which was fol- 
lowed by the occurrence of a tumor about the locality of the inflam- 
mation, as the pelvis or the appendix. 

If the obstruction is due to stricture from cancer of the intestine, the 
symptoms of that affection are present. A tumor can be made out at 
some situation in the course of the bowel. The symptoms are (1) the 
cachexia, emaciation, and ansemia ; (2) pain ; (3) tumor ; (4) constipa- 
tion with scybalous discharge ; (5) bloody discharge ; (6) mucous dis- 
charge. If the cancer is seated in the rectum, we find tormina and 
tenesmus, and the discharge of blood and scybalous masses. Local 
examination reveals the presence of a malignant mass. Obstruction 
due to stricture from the healing of an ulcer is seated in the rectum or 
sigmoid flexure of the colon. Pain and a sense of obstruction are 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 847 

referred to that locality. A history of syphilis may be obtained, and 
frequently the rectal tube, or the finger, will detect the stricture. In 
both instances there is a history of imperfect, irregular action of the 
bowels from time to time, with intervals of comparative comfort. 
These symptoms precede the constipation. When feces accumulate in 
the colon the larger accumulations take place in the sigmoid flexure 
and in the caecum. Fecal tumors, described under Constipation, are 
felt through the abdominal walls. Obstruction from fecal accumula- 
tion is preceded by a history of constipation (q. v.). The accumula- 
tions can be easily discerned as a rule. It must not be forgotten that 
chronic intestinal obstruction may at any time become acute. 

Chronic intestinal obstruction always occurs in adults. The onset is 
gradual. The pain that attends obstruction of this form is intermit- 
tent, and if there is fecal accumulation, it is not very prominent. 
Vomiting occurs late in the disease, is small in amount, and generally 
is not a prominent factor. Obstruction to the passage of feces may be 
constant, or alternate with diarrhoea. In fecal accumulation it be- 
comes complete, although spurious diarrhoea may attend it. The dis- 
charges may be bloody, which points to cancer. Tenesmus is present 
in stricture low down in the large bowel. Meteorism is not marked 
when the obstruction is high up, as in acute obstruction. When the 
obstruction is in the large intestine it may be extreme, and in fecal 
obstruction gradually increases as the obstruction becomes more 
marked. Coils of intestine in peristaltic movement are seen only in 
cases in which there is marked emaciation. 

The forms of chronic obstruction that are attended by tumor have 
been mentioned. 

The Differential Diagnosis. It is essential in order to distin- 
guish the form of acute obstruction to ascertain the nature of the ob- 
struction, and to determine, if possible, its site. 

The Nature of the Obstruction. Various factors must be 
considered in order to estimate the cause of the obstruction. 

The Age. Obstruction from intussusception occurs early in life ; 
from bands or through apertures, in adult life, usually prior to forty 
years of age ; from volvulus, between forty and sixty years. Obstruction 
due to a gallstone occurs during the middle or later period of life — 
always after the fortieth year. 

The Previous History. In obstruction by bands of adhesion there 
is a history of peritonitis, or, as Treves points out, previous attacks of 
obstruction more or less marked. In volvulus the patient has been 
subject to constipation prior to the attack, and in intussusception there 
has been no previous history, unless polypus was present, causing drag- 
ging, colicky pains, and occasional discharge of blood. 

The Symptoms. The symptoms of the various forms of acute obstruc- 
tion vary somewhat. Pain in strangulation, from bands or hernia, is 
severe and paroxysmal in character, attended by collapse. It occurs 
early in volvulus, though it is not so severe as in the former, and 
occurs at long intervals, becoming constant with exacerbations. In 
acute intussusception the pain occurs early, and is steady. It in- 
creases, and then may suddenly subside. At first it is paroxysmal, 



848 SPECIAL DIAGNOSIS. 

attending discharge of blood and mucus from the bowels. Local ten- 
derness in the first group of cases occurs late. In volvulus it occurs 
early, and may be noted over distended coils. In intussusception it is 
usually common about a sausage-shaped tumor. Vomiting is marked 
and occurs in strangulation, soon becomes feculent, and increases the 
severity of the paroxysms of pain. In jejunal obstruction it is ex- 
cessive and non-feculent. In volvulus it does not come on so quickly, 
but is severe and constant when it takes place. The relaxation that 
attends vomiting often affords relief to the obstruction. In intussus- 
ception it does not occur as early as in the other forms, and is not so 
severe. It becomes feculent in only a small number of cases. Con- 
stipation is continuous in all cases except intussusception. In the 
latter there is some constipation, but it is not absolute ; diarrhoea is 
not uncommon, and discharge of blood in the stools occurs in 80 per 
cent, of the cases, according to Treves. Prostration is severe in all 
cases, although probably not so marked in volvulus. Because of its 
close proximity to the rectum tenesmus occurs m volvulus. It is of fre- 
quent occurrence in intussusception, often beginning early in the attack. 

The Physical Signs. (Plate XXXIX. , Figs. 1 and 2.) On palpa- 
tion of the abdominal wall it is noted to be soft and flaccid in most of 
the cases, unless peritonitis has ensued. This occurs early in volvulus, 
hence rigidity is marked. In a large number of cases a tumor can be 
made out only in intussusception. It is seated in the lower right 
quadrant of the abdomen. Early in the attack it is oblong and of 
sausage-shape. When peritonitis ensues it disappears, on account of the 
tympany. A portion of the gut may protrude at the anus, or be felt 
on rectal examination. Meteorism occurs about the third day in a 
strangulation ; it occurs early, is very rapid and pronounced in volvu- 
lus, and is absent in intussusception, unless constipation or peritonitis 
takes place. It is not marked in high obstruction. 

The Site of the Obstruction. The seat of obstruction is in a 
measure indicated by (1) the location of the pain or abnormal sensa- 
tions, (2) the character of the swelling, (3) the character of the stools, 
(4) the degree of meteorism, (5) the results of a rectal examination, (6) 
the change in the urine, (7) the general condition. The patient is 
often able to indicate the location of the obstruction fairly well by the 
sensations of obstruction or fulness and by the great relief experienced 
when a free evacuation of the bowels is naturally or artificially pro- 
duced. On auscultation, when the bowel is irrigated, a murmur, like 
the deglutition-murmur, may be heard at the point of constriction of 
the gut. In obstruction high up there is but little meteorism, the 
tumor is usually not detected, and pain is seated about the umbilicus 
or the upper quadrants of the abdomen. Obstruction at the ileo-caecal 
valve may be indicated by a tumor in the lower right quadrant over 
the region of the valve or just above it. It is usually at this point 
that invagination takes place, and hence we may look for a tumor in 
this situation. (Plate XXXIX., Fig. 1.) On the other hand, in vol- 
vulus of the colon, or stricture of the rectum, the obstruction, being 
low down, is attended by much meteorism and by pain in the left 
lower quadrant of the abdomen. A tumor may be detected in this 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 849 

position. The position of the obstruction is sometimes indicated by 
the seat of peristalsis. This may be seen to stop at a given point, 
which usually indicates the position of the obstruction. The seat of 
obstruction may be indicated by the number of coils of intestine that 
are engaged in the peristaltic movement. The coils of intestine in front 
of the tumor are dilated and hypertrophied. In active movement they 
cause prominences which follow the course of the bowel. Wyllie has 
called them " patterns of abdominal tumidity." If the obstruction is 
in the jejunum, peristalsis may not be observed. If the lower end of 
the large intestine is obstructed, the colon is prominent ; if the gut 
about the ileo-csecal valve, the region about and below the umbilicus is 
prominent. The Urine. The position of the tumor, it is said, can be 
ascertained by changes in the urine. When the obstruction is in the 
small intestine, indican is much increased from the decomposition of 
albuminous substances and products of putrefaction. In this location 
the urine may be suppressed. In stenosis of the large intestine indican 
is not increased unless there is cancer. The value of the information 
derived from the character of the stools and the results of rectal 
examination are obvious. Obstruction in the duodenum or jejunum is 
followed by rapid collapse and anuria. In general, it may be said the 
more severe and rapid the symptoms the more likelihood that the 
obstruction is in the small intestine. 

Intussusception (Plate XXXIX., Fig. 1), or invagination, occurs 
most frequently in children prior to the tenth year. It is characterized 
by severe colic and pain in the abdomen, first complained of about the 
navel. The severity increases in paroxysms, and only lessens if com- 
plete strangulation has taken place. With the onset of the pain there 
are one or two movements of the bowels, which contain mucus and 
blood. After this there may be constipation, or the stools continue to 
be loose, and are as frequent as fifteen of twenty in a day. Sometimes 
they are quite bloody, and almost always there is some tenesmus. In 
a short time after the attack vomiting commences. It may be constant 
or occur only after taking food. At first the abdomen is soft, but 
tender on pressure. A sausage-like tumor can be felt on the right side 
below the transverse umbilical line. On inspection of the rectum a 
portion of the intestine may be seen, dark and gangrenous in appear- 
ance, or it may be felt by palpation. If there is much tenesmus, the 
anus often remains open. In rare cases the bowel may slip back and 
the symptoms subside spontaneously. On the other hand, peritonitis 
may rapidly ensue, with high fever, followed by collapse and death. 

Diagnosis. It must be distinguished from the enter o-colitis of child- 
hood or the proctitis due to a polypus. In entero-colitis there is no 
tumor, and the collapse and prostration do not occur so early and are 
not so rapid. There is greater likelihood of a number of the stools 
being greenish, like spinach. In a polypus of the rectum the symp- 
toms are local. The child is worn out and restless, but great abdominal 
tenderness, and the tumor, meteorism, vomiting, and collapse are absent. 
The rectum must be examined. 

Intussusception must be distinguished from peritonitis, in which 
symptoms of stenosis of the bowel from ileus paralytica may be present. 

54 



850 SPECIAL DIAGNOSIS. 

The history and sequence of events must be watched carefully. Often 
the commencement of the affection about hollow viscera which have pre- 
viously been the seat of disease, or its onset with sudden perforation, 
will point to the nature of the affection. In peritonitis there is no 
active peristalsis ; there is general distention of the abdomen , with 
general tenderness ; the urine is diminished, but does not contain in- 
dican in excess. Collapse ensues rapidly. Signs of effusion within 
the abdomen may appear. 

It must be distinguished from embolism or thrombosis of the mesenteric 
artery and infarction of the bowel. In the latter the symptoms take 
place suddenly. The patients have reached middle or late life, and have 
atheroma of the general arterial system. Sudden pain in the abdomen, 
with vomiting and symptoms of collapse, takes place. Moderate ob- 
struction occurs, with distention of the abdomen. After the pain diar- 
rhoea with the passage of blood follows. The age and the absence of 
tumor distinguish it from intussusception, the only intestinal condition 
for which it may be mistaken. 

Hernia and Constriction by Bands. Obstruction due to these con- 
ditions occurs in adults after the fortieth year of age, in both sexes. 
In stricture from pressure of bands there has usually been a history of 
previous attacks of peritonitis or of inflammation of the structures in 
relation to the peritoneum. Hence, a cholecystitis or appendicitis are 
often found to precede the obstruction. The attacks begin suddenly, 
and the symptoms may from the start be most pronounced. They are 
the typical symptoms of intestinal obstruction. The local tenderness, 
however, may not be present as early as in other forms of obstruc- 
tion. It is quite characteristic not to find a tumor or positive local 
cause for the obstruction, and also not to have meteorismus. This is 
due to the fact that the obstruction is usually high up in the intestinal 
tract. 

Volvulus. Volvulus occurs most frequently in males. It occurs 
late in life, and is usually preceded by a history of constipation. Pre- 
monitory symptoms may have been present for a few days, but the 
symptoms of obstruction develop suddenly. They are the symptoms 
of acute obstruction, but as the lesion is in the lower portion of the 
bowel, meteorismus is present to a marked degree, and rectal symp- 
toms are found. Tenesmus is present in a small proportion of the 
cases. Peritonitis is likely to set in early, with increase in the temper- 
ature, increased tenderness of the abdomen, and more pronounced 
symptoms of collapse. 

Diagnosis of Intestinal Obstruction from Other Conditions. Intestinal 
obstruction must be distinguished from peritonitis and appendicitis. 
This is sometimes very difficult. Careful attention must be paid to the 
evolution of the case and the history of previous abdominal disease, or 
of lesions on account of which, on the one hand, peritonitis may occur, 
or, on the other, obstruction of the bowel. In peritonitis the attack 
follows disease in the uterine appendages, the vermiform appendix, or 
the gall-bladder, or perforation in some portion of the gastro-intestinal 
tract. Fever usually attends the inflammation, with or without chill. 
Vomiting will probably occur at the onset, and then subside until the 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 851 

peritonitis becomes general. The first paroxysms of vomiting are appar- 
ently due to shock. The vomiting that occurs rarely becomes feculent. 
As the peritonitis advances the vomiting becomes passive ; a simple 
constant regurgitation of a large amount of fluid, greenish or grayish- 
yellow, or watery, takes place. It pours into the mouth, and is simply 
discharged without the occurrence of retching. The abdomen is swollen 
and tympanitic. The symptoms due to excessive tympany are more 
marked than in intestinal obstruction. As the diaphragm is interfered 
with, breathing is hurried. The abdomen is tender on pressure and is 
the seat of general pain. The general pain and tenderness, however, 
can usually be found to be more marked at the possible primary focus 
of the disease. Further, on local examination, in these positions ful- 
ness or undue prominence or swelling may be observed. On palpation 
over the point of origin there may be localized oedema. The symptoms 
of collapse do not differ from those of intestinal obstruction in marked 
degree, although the peculiar appearance of the face and other nervous 
features occur more rapidly in peritonitis than in obstruction. It must 
be remembered that peritonitis in a large majority of cases attends ob- 
struction. 

In appendicitis the symptoms are somewhat like those of intestinal 
obstruction. There may be constipation and vomiting. The former 
is not pronounced, and can usually be relieved. Vomiting subsides 
after the first twenty-four hours, unless peritonitis supervenes ; it is 
never stercoraceous. The local physical signs are characteristic. In 
appendicitis there is fixed tenderness on pressure at McBurney's point. 
Some swelling can almost always be observed. On light or deep per- 
cussion there is change in the note as compared with the other side. 
Fluctuation can often be detected in from two to four or five days. 
Both the tumor and fluctuation can be detected by bimanual examina- 
tion of the abdomen and flank. Examination by the rectum may 
reveal a tumor at the brim of the pelvis in the right side. Fever 
attends the attack throughout. When peritonitis supervenes there is 
rigidity of the entire abdomen, which at first was localized to the right 
lower quadrant. 

Intestinal obstruction must not be confounded with enteritis. In all 
forms there is diarrhoea, in many vomiting. Pain of a colicky nature, 
spreading from the neighborhood of the umbilicus, is marked when- 
ever obstruction to the passage of feces or gas takes place. Vomiting 
is not stercoraceous, and the general symptoms, collapse, etc., do not 
occur. Acute hemorrhagic pancreatitis is also attended by symptoms 
similar to those of intestinal obstruction. There is sudden severe pain 
in the upper half of the abdomen, with vomiting and the rapid develop- 
ment of collapse ; there may be constipation ; the situation of the pain is 
of some significance. Vomiting never becomes stercoraceous ; flatus can 
usually be passed and the bowels opened by an enema. Meteoiismus does 
not take place, although the epigastrium is tympanitic. If the symp- 
toms are not so severe, there may be increased dulness, and possibly a 
tumor on deep palpation in the left upper quadrant of the abdomen 
along the margins of the ribs, which should be dull on percussion, or, 
on account of its relation to the stomach, give a dull tympanitic note. 



852 SPECIAL DIAGNOSIS. 

The symptoms of internal hemorrhage are present, pallor of the face 
and extremities, syncope, and, in addition, prostration and other symp- 
toms of collapse. 

Cancer of the Intestines. (Plate XXXIX., Fig. 2.) Obstruc- 
tion must not be confounded with carcinoma of the intestines. The 
disease usually occurs late in life, and is associated with progressive 
emaciation and cachexia. There may not be any symptoms save general 
failure of health until the sudden occurrence of obstruction of the bowel. 
The symptoms vary with the position of the carcinoma and the direc- 
tion of growth of the tumor. In some instances Avith the general symp- 
toms there may be irregular pain in the abdomen, with irregularity of 
stools. The tumor may be detected if the small intestine is involved 
Its detection is facilitated by having the patient get on the hands and 
knees and palpating the abdomen in this position, and by clearing out 
the colon by a large enema. On auscultation the water may be heard 
to enter the dilated colon beyond the tumor, the sound resembling the 
deglutition-murmur at the cardiac end of the stomach. If the tumor is 
situated in the lower colon, pain in the sacral region, resembling sciatica, 
may be complained of ; if the csecum or the sigmoid flexure is the seat 
of disease, a tumor is usually detected. Wherever the situation, the 
tumor found is tender, usually lying in the axis of the intestine — 
movable if in the small intestine, fixed if in the csecum or the sigmoid 
flexure. In the latter location the tumor may be felt per rectum. One 
notable characteristic is that it may be palpable some days and not be 
present at other times. The position and size may vary from day to 
day, although it is always hard and knotty, not doughy. By means of 
the proctoscope, with the patient in the knee-chest position, as described 
by Kelly, the presence of tumors of the descending colon will be dis- 
closed. Constipation is characteristic of most of the cases. It may 
alternate with diarrhoea. Paralysis of the sphincter ani may take place, 
with incontinence. The stools are frequently ribbon-shaped, or they 
may pass in scybalous masses, and large or oftener small amounts of 
blood, chiefly the latter, are passed with pus or mucus ; sometimes 
masses resembling cancer can be found in the stools. If the tumor is 
in the rectum, there is great difficulty in defecation ; the act is attended 
by pain. Later the pain becomes constant, and may radiate to the 
hip or the genitalia. Sometimes this pain is the only symptom com- 
plained of. 

The diagnostic symptoms are : (1) The general symptoms of cancer. 
(2) The tumor. (3) The occurrence of constipation which leads to 
complete obstruction, or obstipation, alternating with diarrhoea. Blood 
in the stools, with alteration in the shape of the feces, is significant. 1 

Diseases of the Rectum. 

Consideration of rectal lesions belongs to the surgeon. It is proper, 
however, to insist upon the very frequent deleterious effect of such 
lesions in neurasthenic subjects. Indeed, the bleeding which attends 

1 Musser: "Carcinoma of the Descending Colon." Univ. Med. Mag., 1896. 



DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 853 

hemorrhoids may be sufficient to lead to profound anaemia, upon which 
neurasthenia may readily develop. The local suffering due to rectal 
fissure, or prolapse, may aggravate any tendency to the state of neuras- 
thenia, or aid materially, with other conditions, to fasten it more 
firmly upon the system. In cases of anaemia, of neurasthenia, of the 
gastric neuroses, of debility, or prostration, the cause of which cannot 
be ascertained, the rectum should be examined. The appearance of 
hemorrhoids and other rectal affections is described in works on surgery. 
Hemorrhoids, ulcers, fistula, and carcinoma are to be sought for in 
abdominal affections. 

Inspection and palpation are necessary. The symptoms are those of 
local pain, tenesmus, and frequently hemorrhage. The pain follows a 
movement of the bowels. There may be a feeling as of a foreign body 
in the rectum, with some itching and burning about the anus. The 
pain may be so severe as to inhibit defecation. The timid subjects 
will not endure the act ; in consequence they suffer from vertigo, head- 
ache, tympanites, and symptoms of gastro-intestinal disorder. In 
some instances there is chronic catarrh of the rectum, with discharge 
of small stools containing mucus or pus streaked with blood. Cases 
occur in which hemorrhage is the only symptom, the constant recur- 
rence of which leads to grave constitutional results. Hemorrhoids are 
the lesions for which the rectum is most frequently examined. They, 
as well as other lesions, are of diagnostic significance in affections 
beyond the rectum. Thus in all forms of portal congestion internal 
hemorrhoids are of constant occurrence, and when found in a toper 
may be one of the first indications of cirrhosis of the liver. Rectal 
fissure is not of much diagnostic significance. The finding of a small 
cancer, the symptoms of which may be those of hemorrhoids, may ex- 
plain emaciation and the development of cachexia. Ulcer of the 
rectum may be due to syphilis, cancer, or tuberculosis. A fistula is 
often tuberculous. The rectum must be examined in cases of pyaemia, 
particularly of the portal variety, when jaundice, enlargement of the 
liver, and hectic fever are present, for local rectal disease may cause 
pylephlebitis. 



CHAPTEK VI. 

DISEASES OF THE LIVER, SPLEEN, AND PANCREAS. 

The symptoms of disease of the liver are due to the morbid pro- 
cesses, to disturbance of the functions of the hepatic cells, or to obstruc- 
tion of the channels for the flow of blood and of bile. As these channels 
extend beyond the glandular structure of the liver they may be affected 
by disease outside of the organ. Hepatic symptoms may, therefore, be 
due to diseases other than those of the liver. 

The morbid process may, in time, cause alterations in function, ob- 
struction of channels, or physical alterations in the size and shape of 
the liver. But the channels may be obstructed and the size and shape 
of the liver changed by disease outside of the liver. 

Symptoms due to the Morbid Process. The morbid processes 
are the congestions, the inflammations, the degenerations, the morbid 
growths, and gross parasites. 

In congestion of the liver the symptoms are (1) the symptoms of the 
cause, (2) enlargement of the organ from the increased amount of 
blood, (3) functional disturbance from the same cause. The conges- 
tion is not limited to the vessels in relation with the liver-cells, but 
involves the vessels of the mucous membrane also, hence the latter 
swell, obstruct the ducts, and produce jaundice in moderate degree. 
The inflammations are toxic and infectious. The symptoms are due 
to the cause (intoxication or infection), to the degree of obstruction of 
the vessels and ducts, to the shape and size of the liver, and to the 
alteration of its function. When the inflammation is diffused, as in 
the cirrhoses, the hepatic symptoms are more marked ; when local, as 
in abscess, the infectious symptoms are in preponderance. If the 
ducts are the seat of infection, the bile channels are obstructed — jaun- 
dice arising ; if the vessels, ascites. In morbid growths of the liver 
the symptoms are those of malignant disease in general, to which are 
added symptoms due to change in the size of the liver, and, more fre- 
quently than in inflammation, symptoms due to obstruction of the 
channels. The degenerations are so frequently secondary to and 
masked by the symptoms of their primary cause that, save in regard 
to change of size, there are no hepatic symptoms worth mentioning. 

Symptoms due to Functional Disturbance of the Liver. 
The functions of the liver are to secrete bile ; to destroy the haemoglobin 
of the blood ; to destroy, modify or neutralize poisons entering, or to 
modify and render available for nutrition the peptones absorbed by, the 
portal circulation ; the elaboration of glycogen. Bile is not secreted 
when the liver-cells are destroyed, as in acute yellow atrophy. The 
liver does not destroy the usual amount of haemoglobin. On the other 
hand, haemoglobin may be so much in excess that the liver cannot 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 855 

destroy it ; jaundice then results. (See Hematogenous Jaundice.) Func- 
tional disturbances of the liver are manifested clinically by symptoms 
due to the entrance into the circulation of imperfect products of diges- 
tion, or poisons not destroyed by the liver. 

Lithcemia is a common toxic condition, and is believed to be due to 
functional liver-disturbance. There is an excess of uric acid and 
urates, or of other metabolic compounds in the blood. It may be a 
convenient term for the auto-intoxication which takes place in disease 
of the gastro-intestinal tract. The symptoms are, first, symptoms of 
excess of lithic acid in the system ; second, the effects of the lithic 
acid upon the nervous system. Lithsemia may be acute or chronic. 

Acute Lith^mia ; Biliousness. When acute the local disturb- 
ances are : furred tongue, a bitter taste in the mouth, anorexia, nausea, 
disgust at the sight of food, with possible morning vomiting. There 
is some tenderness in the upper mid-abdomen, and, after eating, weight 
and f nlness and distress in that region. Flatulency occurs. Symp- 
toms of intestinal dyspepsia may arise secondarily. Slight fever or 
feverishness may attend the attack. The skin is hot and burning ; or 
cold perspirations may break out at irregular times, alternating with 
flashes of heat. The bowels are constipated, the stools are clay-col- 
ored. The symptoms may be attended by slight obstruction to the 
ducts, causing a moderate degree of jaundice. In some instances the 
liver is slightly enlarged. The urine is loaded with urates and uric 
acid. It is scanty and high-colored, and there may be painful mictu- 
rition. The nervous symptoms are usually those of depression, as head- 
ache, some dulness, or stupor ; the patient may be unusually drowsy. 
The headaches may be the most prominent feature of the attack. They 
are frontal, attended by slight vertigo, flashes of light or spots before 
the eyes, and ringing in the ears. 

The same group of symptoms is seen in acute g astro-duodenal catarrh. 

Chronic Lith^mia. In chronic lithwmia the symptoms are varia- 
ble, and are characterized by disturbance of function in nearly all the 
organs of the body. They have been classically described by Murchi- 
son, Da Costa, and others, and while the theory is fairly satisfactory 
to work upon for lines of treatment, the same group of symptoms may 
be met with in forms of chronic indigestion, particularly the forms in 
which there is inability to digest sugars and starches. The symptoms 
are attributed by some to chronic intestinal catarrh. 

Symptoms. The patients are in ill health and subject to chronic 
indigestion. They may be under weight or corpulent. The skin is 
harsh and dry, its nutrition poor. It is subject to erythema ; or local 
inflammations, as eczema, may arise. Irregular sweats occur, alter- 
nating with intervals when the skin is hot and dry. The extremities 
are cold and clammy, and tingling and numbness are often com- 
plained of. 

Gastro-intestinal Symptoms. The symptoms are those of chronic 
indigestion. There is constantly a furred tongue with local dyspeptic 
symptoms. The bowels are irregular or constipated ; sometimes 
mucus is passed. Flatulency is excessive, both gastric and intestinal. 
An icteric tinge may be seen on account of a slight local catarrh of the 



856 SPECIAL DIAGNOSIS. 

ducts, or of hepatic congestion. It recurs at frequent periods, while a 
sallow complexion is more or less constant. 

Respiratory Symptoms. The patient is liable to attacks of catarrh 
of the upper air-passages, and especially to pharyngitis. In lithsemic 
states tonsillitis is not uncommon. Chronic pharyngitis is present. 
On the other hand, some persons, particularly those over fifty years, 
have chronic bronchitis, and attacks of asthma are common. The 
bronchitis cannot be distinguished from that due to other causes, except 
by the fact that the subject is lithsemic. Emphysema of the lungs 
develops on account of bronchitis and tissue degeneration. 

Cardiae Symptoms. Palpitation is a constant accompaniment of 
many forms of lithsemia ; in others there may be unduly rapid action 
of the heart, or, during exacerbations, slowness of the heart's action. 
In the later stages pseudo-angina pectoris is of common occurrence. 
In the earlier stages pain about the heart or in the left side is fre- 
quently complained of. 

Nervous Symptoms. Constant headache, worse in the morning, re- 
lieved toward the end of the day. Some vertigo may be present. 
Depression of spirits and inaptitude for mental exertion exist. The 
memory is dull, the faculties blunted. The patient is subject to back- 
ache, chiefly in the loins. Pain in the right shoulder is of frequent 
occurrence. In addition, pains along the course of the nerves (neuritis), 
and myalgias, are of common occurrence. The nerve-trunks may be 
tender. There is tenderness in the sheaths of the muscles, or at the 
insertions of fasciae and tendons. Peripheral nerve-sensations are 
common. Numbness and tingling are frequently complained of. 
Parsesthesise of all forms, variously distributed, are a source of annoy- 
ance. Local sensations of heat or burning alternate with areas of 
coldness. Tingling, pricking of needles, and other forms of pares- 
thesia occur. 

The Urine. The urine is high-colored and contains an abundance 
of uric acid and urates. The amount is scanty, the specific gravity 
high. There may be albumin, small in amount, depending upon the 
irritation of the urates in their passage through the kidneys. Cylin- 
droids are present ; casts are not common, although at times, when 
the uric acid is passed in excess, there may be a secondary nephritis, 
with albumin, blood, and casts. As an ultimate result of such condi- 
tion we may have gallstones, or calculi in the kidneys and bladder. 
Lithsemic patients are subject to attacks of hepatic or renal colic. 

As part of the same process or an accompaniment we may have 
gout or rheumatism. Acute inflammatory rheumatism (rheumatic fever) 
does not belong to this category, but muscular rheumatism, subacute 
inflammation of the joints with moderate fever, true gout, and gout 
with its modifications Avhen seated in the various joints, are the ultimate 
results of this process in the patient. Attacks of gout may occur in 
a patient who has not shown any symptoms of lithsemia, but those 
who have symptoms of lithsemia are more susceptible to causes which 
produce attacks of gout. The gouty and rheumatic manifestations are 
due to the deposition of uric acid and urates in tissues which are not 
highly vitalized, and in which, therefore, the circulation is sluggish. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 857 

Lithsemia later assumes the gouty aspect. Tophi are seen in the 
situations natural to them. The appearance of the face is character- 
istic, with capillary congestions and stases. The patients usually be- 
come more or less obese and are subject to attacks of glycosuria. 
Early in their life degenerations of vessels take place. The kidneys 
are always under an excessive strain. A good deal of material is not 
discharged ; its effects upon peripheral vessels are such as to cause 
vasomotor spasm and heightened tension, leading to low-grade inflam- 
mations, with the development of atheroma. For the same reason 
chronic interstitial nephritis is set up, and, because of heightened strain 
in the vascular system, chronic sclerotic valvulitis. 

Functional symptoms from disorder of the liver are otherwise not 
marked, unless we include a group of cases in which sudden coma and 
convulsions take place, presumably because material has been absorbed 
from the gastro-intestinal tract and enters the general circulation 
through the temporary cessation of the function of the liver, the office 
of which is to destroy the material. Such symptoms may arise in 
organic disease of the liver, as cirrhosis. 

Symptoms due to Obstruction of the Channels. (1) Obstruc- 
tion of the bile-duets, either from disease or external pressure, causes 
jaundice, pain, and fever. The three symptoms may occur singly or 
combined. Jaundice may occur alone in obstruction by gallstones ; 
pain may occur with it ; or jaundice, pain, and fever may occur 
together ; rarely, pain or fever may be present alone. Each symptom 
will be described later. (2) Obstruction of the blood-channels causes 
congestion of the liver, which may be active or passive, or portal ob- 
struction. The symptoms of each will be discussed ; suffice it to say 
that here again the symptoms are modified by the process. Thus in 
portal obstruction from pressure the symptoms are quite different from 
those in portal obstruction due to suppurative inflammation of the vein. 

Congestion of the Liver. In the congestions the liver is enlarged. 
If the hyperemia is active, painful distention may be complained of, 
and the organ may be the seat of some tenderness. There may be, in 
addition, weight and fulness in the liver-region. Active hyperemia 
may follow a chill or suppression of the menses, but more frequently 
occurs after indiscretions of diet, the free use of alcohol, or stimulating 
food, followed by an attack of acute gastro-intestinal catarrh. It is 
more common in the tropics, and is due in that climate to suppression 
of the perspiration. It is recognized by the occurrence of symptoms 
of acute gastritis with enlargement, pain, and tenderness of the liver. 
Slight jaundice may attend the attack. 

Passive congestion is also attended by enlargement of the liver. The 
enlargement may cause a sense of weight or fulness, but pain is not 
complained of. The organ is not tender, the edges are smooth and 
indurated. The liver may pulsate. This is detected by placing the 
hand over the surface of the liver, when, with each impulse of the heart, 
the organ can be felt to expand. The symptoms of the cause of the 
passive congestion combine with those just enumerated as due to en- 
largement of the organ. In addition we have symptoms due to obstruc- 
tion of the flow of blood in the portal circuit. 



858 SPECIAL DIAGNOSIS. 

Passive congestion occurs in organic heart disease after compensa- 
tion has failed and the right heart is dilated. The organ rapidly be- 
comes congested because of its close proximity to this chamber. In 
emphysema of the lungs, in fibroid phthisis, in intrathoracic tumors 
pressing upon the vena cava, mechanical congestion also takes place. 
The recognition of passive congestion is not difficult. The symptoms 
due to enlargement (see Objective Symptoms) and the symptoms due 
to portal obstruction point to the true nature of the morbid process. 

Portal Obstruction. Disease of the portal vein or occlusion of its 
branches in the liver, obstructs the flow of blood. The diseases of the 
portal vein are thrombosis, and adhesive and suppurative inflammation. 
Obstruction of the terminal venous radicles in the liver is caused by 
cirrhosis. 

Thrombosis of the portal vein attends cirrhosis of the liver, or may 
occur secondarily to pressure upon the vein by a tumor. Disease of 
the pancreas was the cause of the pressure in a patient under my 
observation. As a result of thrombosis adhesive inflammation of the 
vein takes place, with or without the establishment of a collateral cir- 
culation to replace its function. 

The symptoms of disease of the trunk of the portal vein are the same 
as those of obstruction of the terminal branches, and are known as the 
symptoms of portal congestion. (See below.) In one respect only do 
they differ. While we have ascites in both, in thrombosis of the 
portal vein it occurs suddenly, and is characterized by rapid recurrence 
after tapping. 

Suppurative inflammation of the portal vein is attended by symptoms 
resembling pyaemia, and is also called portal pycemia. The inflamma- 
tion is secondary, and depends upon inflammation in the portal area. 
It may follow appendicitis, infectious inflammation of the hemorrhoidal 
veins, or of the veins anywhere in the gastro-intestinal tract. Pus is 
carried into the liver by the portal current. In consequence thereof, 
multiple hepatic abscesses arise. Three pathological affections are 
therefore seen : (1) Suppuration in the portal area ; (2) inflammation 
of the vein ; (3) multiple abscesses of the liver (for the symptoms of 
which see Abscess). 

Occlusion or overfilling of the branches in the liver occurs in passive 
congestion, and most typically in cirrhosis of the liver. The circula- 
tion in the liver is interfered with ; the blood is thrown back into the 
portal vein, and overfills the vessels of the portal area. As a result 
we have (1) congestion of the mucous membrane of the stomach and 
bowels, with the symptoms of gastro-intestinal catarrh. (2) Dilatation 
of the veins, chiefly the hemorrhoidal, giving rise to hemorrhoids. (3) 
Ascites. (4) Hemorrhages. The hemorrhages may occur in any part 
of the gastro-intestinal tract. Hsematemesis and intestinal hemor- 
rhage are seen singly or combined. The vomited blood may be small in 
amount, often with mucus. In some cases large, sometimes fatal, hemor- 
rhages take place either from the mucous membrane of the stomach or 
from the veins about the oesophagus, which often become varicosed in 
cirrhosis. Hemorrhages from the intestine may be from enlarged 
hemorrhoidal veins, from an intestinal ulcer, or from the intact mucous 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 859 

membrane. (5) Enlargement of the spleen. (6) Changes due to the 
collateral circulation. If complete collateral circulation is established, 
the above symptoms may not ensue. The collateral circulation may 
be through deep-seated or through superficial veins. If the latter, 
the external veins of the abdomen are enlarged. The epigastric and 
mammary veins become prominent. The veins about the umbilicus 
may become so enlarged and prominent as to form a swelling, to 
which the term caput Medusw has been applied. The venules along 
the line of attachment of the diaphragm in the lower thoracic zone 
are overdistended. They may be the seat of pulsation. 1 

In consequence of the portal overfilling the enlarged terminal 
branches of the vein press upon contiguous structures, interfere with 
the circulation of blood in the major vascular system of the liver, and 
invite catarrh of the terminal ducts, with obstruction, and hence jaun- 
dice. This is seen quite frequently in passive congestion of the liver, 
rarely in cirrhosis. 

Symptoms due to the Changes in Shape and Size. The liver 
may be enlarged, contracted, or irregular. (See Objective Symptoms.) 

When the liver is contracted symptoms of portal obstruction usually 
occur ; when enlarged they occur occasionally. 

The Data Obtained by Inquiry. 

A knowledge of etiological factors is of aid in the diagnosis of 
hepatic affections. In disease of the liver more than in any other 
organ of the body we find the affection secondary to disease elsewhere. 
Moreover, diseases of the liver are almost always associated with defi- 
nite causes, the presence or absence of which is of great diagnostic sig- 
nificance. In the study of hepatic disease we consider, therefore, 
among etiological factors, the age, the sex, the habits of life, the 
climate, and the presence or absence of disease in other portions of the 
body. Primary liver disease is comparatively rare. Secondary liver 
disease, on the other hand, is of common occurrence. There are but 
few general diseases or states of the system that do not in some way 
influence the liver. The above remarks refer to organic disease. Func- 
tional disorders of the liver, as previously remarked, are so difficult 
to separate from functional disorders of the stomach and intestines, 
that, practically, from an etiological and clinical stand-point, they go 
hand-in-hand 

The Social History. The Age. Diseases of the liver usually 
occur late in life, because the causes upon which they depend are oper- 
ative only at that period. In a case, therefore, of ill health in a young 
subject, when the cause cannot well be determined, the liver is not so 
likely to be the seat of disease as in older subjects. Late in life we 
have gallstones with their multiple consequences, inflammation, cir- 
rhosis, and cancer. We may, however, have the congestions and the 
degenerations in early life, although not so frequently. 

The Sex. The sex is not of much significance from a diagnostic 
stand-point. Cancer may be more frequent in the female sex, because 

1 Musser: Trans. Phil. Path. Soc, vol. xi. p. 20. 



860 SPECIAL DIAGNOSIS. 

cancer of the uterus and other organs is more common. Cancer of 
the biliary passages is more frequent in females, because in that sex 
gallstones, which are etiological factors in cancer, are more common. 
Cirrhosis, also, is said to be relatively more frequent in females. 

The Habits. It is always necessary to inquire into the habits. Alco- 
holism points to cirrhosis ; the excessive use of stimulating foods to 
hyperemia ; sedentary habits and the use of starches and fats to gall- 
stones. The occupation has but little influence in the development of 
hepatic disease. With regard to the climate, it may be said that in 
tropical countries hyperemias and abscess of the liver are more fre- 
quent. 

The Family History. But little avails in the study of the family 
history for diagnosis, as most of the morbid processes are secondary 
to disease elsewhere. This does not apply to biliary calculi, the 
formation of which appears to be confined to members of special 
families. 

Previous Disease. It is absolutely essential to inquire into this 
to establish a diagnosis, as liver disease is usually secondary. The 
occurrence of heart disease or obstructive lung disease points to a con- 
gestion ; infectious diseases to cirrhosis when that is not otherwise 
accounted for ; dysentery to abscess ; ulceration or suppuration in the 
portal area to multiple abscess ; syphilis to syphilitic diseases ; tuber- 
culosis, suppurations, bone disease, and syphilis to amyloid disease ; 
pyaemia to multiple abscesses ; tuberculosis to fatty liver. 

The Subjective Symptoms. 

The subjective symptoms are such as belong to functional disorder 
of the liver, conspicuous among which are gastro-intestinal symptoms 
and toxaemia. (See Functional Disturbance and Lithsemia.) 

Pain is a frequent symptom of liver disease. When sudden in 
onset, acute, and increased by pressure or movement, it is due to peri- 
hepatitis. Acute paroxysmal pain below the ribs or in the epigastrium 
points to gallstones. It may be in the seventh or eighth interspace. 
Pain with distention occurs in congestion. Stabbing or darting pains 
belong to cancer. The pain of perihepatitis may attend abscess. 

Pain in the liver must not be confounded with pleurisy. In pneu- 
monia there is often congestion of the liver and perhaps perihepatitis. 
The associated pain has been mistaken for the pain of hepatic colic. 

The Data Obtained by Observation. The Objective Symptoms. 

Topographical Anatomy. (See Plates XIII., XIV., and XXXV.) 

The right lobe of the liver is applied to the concavity formed by the 
lower lobe of the right lung, being separated from it by the diaphragm. 
The thin lower edge of the right lung overlaps the liver at its upper 
part, but the greater portion of the anterior surface of the right lobe of 
the liver is in contact with the ribs. The under surface of the liver 
is in relation with the stomach, transverse colon, duodenum, right 
kidney, and right suprarenal capsule. " The highest part of its con- 



DISEASES OF LIVER, SPLEEN AND PANCREAS, 861 

vexity on the right side is about one inch below the nipple, or nearly 
on a level with the external and inferior angle of the pectoralis major. 
Posteriorly the liver comes to the surface below the base of the right 
lung, about the level of the tenth dorsal spine. " (Holden.) 

A needle thrust into the right side, between the sixth and seventh 
ribs, would traverse the lung, and then go through the diaphragm at 
its central attachment, into the liver. The lower border of the liver 
extends in the median line, one-third of the distance from the tip of 
the xiphoid cartilage to the umbilicus. In the right mammary line it 
extends to the lower border of the ribs ; and in the mid-axillary line 
to the tenth rib. The upper border is opposite the upper border of 
the sixth rib in the mammary line, and extends horizontally in the 
axilla to the ninth rib behind. 

The attachments of the liver permit of a certain amount of move- 
ment. Hence, the liver can be depressed by deep inspiration, emphy- 
sema of the lungs, or right pleural effusion. If the patient lie upon 
his left side, the left lobe of the liver rises higher and the right ex- 
tends lower, and vice versa if the patient lie upon the right side, the 
liver turning upon the suspensory ligament as an axis. (Gerhardt.) 

Inspection. Inspection is not of very great assistance in the diag- 
nosis of diseases of the liver. Frequently there is a swelling or tumor 
in the right upper quadrant, which may or may not be produced by 
an enlargement of the liver, but which should direct attention to that 
organ. The lower right zone of the thorax may also be distinctly 
prominent. Such a swelling may be observed in amyloid disease, 
hydatid tumor, cancer, abscess, and, less frequently, in fatty liver. 
In amyloid and fatty livers the projection in the right upper quadrant, 
which may extend to the left beyond the median line, presents a 
smooth surface, whereas in hydatid tumor there is frequently a rounded 
projection at some part of the prominent area, and, in cancer, several 
nodules may be large enough to cause slight rounded projections, which 
the eye is more apt to detect after the sense of touch has first directed 
attention to their presence. 

Enlargement and occasionally pulsation of the superficial abdominal 
veins are accompaniments of cirrhosis. 

Jaundice. The Symptoms. The color of the skin and of the mucous 
membranes in jaundice has been described. (See page 121.) In 
addition to the yellow discoloration we find : 1. Irritations of the 
skin. Pruritus is common and intense, and may cause great dis- 
tress. An attack of jaundice may be preceded by general itching. 
It occurs in all forms, but is more marked in obstructive jaundice 
of long duration. Scratch-marks are seen on the surface of the skin, 
and erythematous eruptions and boils frequently occur. Xanthelasma 
is a peculiar affection occurring on the tongue, on the skin of the 
eyelids, and about the ears. (See page 92.) 2. Discoloration of the 
secretions. All the secretions of the body are changed in color, as 
previously described. 3. Bite absent in the feces. The stools are ashy 
or gray in color. 4. Slowness of the pidse. The heart's action falls to 
40 or 30 to the minute, or even lower. 5. Hemorrhages. In the later 



862 SPECIAL DIAGNOSIS. 

stages of all forms of jaundice hemorrhages are of common occurrence. 
In acute malignant jaundice they are seen underneath the skin, and 
come from the mucous membranes. 6. Cerebral symptoms. Irrita- 
bility and depression of spirits are marked. As the disease advances 
the mind grows sluggish ; the patient is dull, and sleeping most of the 
time. Gradually the symptoms of the typhoid state develop. In the 
acute febrile forms coma and convulsions are of common occurrence. 
In the affection known as acute yellow atrophy the cerebral symptoms 
are marked, and occur soon after the onset of the disease. Within 
the first twenty-four hours there may be convulsions, with delirium 
in the intervals, and subsequently coma. 

Causes. Jaundice is of two varieties, the hepatogenous and the 
hematogenous. 

Hepatogenous Jaundice. Jaundice is hepatogenous when there 
is obstruction of the ducts. The obstruction may take place in the 
large ducts or in the smaller terminal ducts. The obstruction may be 
due to disease outside of the ducts ; to disease of the ducts, or to ob- 
struction within the ducts. 

1. Jaundice from disease outside of the ducts. External pressure. 
External pressure by tumors of the stomach, kidney, pancreas, or 
omentum ; by tumors of the liver itself, or enlarged glands in the 
fissure of the liver ; by accumulated feces in the colon ; by an abdom- 
inal aneurism ; and by the pregnant uterus, in rare instances, may cause 
jaundice. Jaundice due to disease outside of the duets is gradual in 
onset, varies in degree with the amount of pressure, and becomes 
chronic, except in pregnancy and from fecal accumulation ; it may 
cause death, or persist until such termination results from the primary 
disease. It is recognized by the absence of pain ; the presence of dis- 
ease in other localities, indicated by its peculiar symptoms and signs ; 
the absence of a history of gallstones ; and, finally, by the patient's 
age. Its nature must be inferred from the symptoms and physical 
signs of disease in neighboring structures. If the jaundice is due to 
enlargement of the lymphatic glands, its nature may be inferred from 
the presence of primary carcinoma in other organs of the body, or from 
the condition of the lymphatic glands in other parts. If they are the 
seat of malignant disease, it can usually be recognized. Cancer of the 
liver must be excluded by its symptoms — enlargement with jaundice, 
with moderate fever, rapid emaciation, and short duration of the dis- 
ease. In the large majority of cases this form of jaundice is due to 
disease of the pancreas, particularly carcinoma. 

2. Jaundice from disease of the ducts themselves. Catarrhal in- 
flammation, suppurative inflammation, or adhesive inflammation of the 
ducts ; and cancer or other tumors of the duct cause jaundice. 

Jaundice due to disease of the ducts presents various features. The 
most common form is that due to catarrhal inflammation of the ducts. 
The jaundice comes on suddenly, at least within forty-eight hours after 
the onset of the symptoms ; there is no pain, but it is attended by 
vomiting and other symptoms of mild gastritis, and is usually accom- 
panied by itching. It follows indiscretions in diet, and occurs in 
young subjects. A definite cause for the gastritis can usually be found. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 863 

The diagnosis is based upon the age, the association of the jaundice 
with gastritis, for which a definite cause can often be assigned ; the 
absence of organic heart disease, or any lesion within the body, on 
account of which jaundice might arise ; the moderate degree of jaun- 
dice, the absence of emaciation and symptoms of portal obstruction, 
the occurrence of moderate enlargement without pain. It must not be 
forgotten that jaundice due to obstruction from gallstones, or to press- 
ure from tumors outside of the duct, is characterized in its onset by 
symptoms similar to those just mentioned. It is often necessary to 
wait before giving an opinion ; a history of previous attacks of jaun- 
dice and the age of the patient, over forty years, also lead to caution 
in the diagnosis. 

If the jaundice is due to suppurative inflammation of the duds, cho- 
langitis, the infection is usually associated with a previous history of 
gallstones. It must not be forgotten, however, that other lesions, which 
cause jaundice, may invite an infectious inflammation of the ducts also, 
such as obstruction by external pressure. The course of the jaundice 
is chronic. Fever and other symptoms of an infection attend it. In 
adhesive inflammation there is a history of trauma from gallstones, and 
the affection is chronic. In eaneer of the gall-ducts the advent of jaun- 
dice is slow, the course protracted ; the symptoms are the symptoms 
of carcinoma, to which are often added the physical signs of an en- 
larged gall-bladder. (See Diseases of the Gall-ducts.) 

3. Jaundice from obstruction within the ducts. Foreign bodies 
within the ducts, as inspissated mucus, gallstones, or parasites, such as 
round worms or hydatid cysts, are the common causes of the occlusion 
of the ducts which may cause jaundice. 

Foreign bodies within the duets cause jaundice by direct obstruction, 
or by the catarrhal inflammation which their presence excites. The 
symptoms occur suddenly in the former instance, gradually in the 
latter. The characteristic symptoms of gallstones precede the jaundice. 
The patient is usually a woman past forty years, with habits of life 
which predispose to the formation of calculi. Colicky pains occurring 
in paroxysms, intermittent jaundice varying in intensity, and an inter- 
mittent fever, point to this form of obstruction. 

Jaundice due to lowering of the blood-pressure in the liver, so that 
the tension between the bile-ducts and the blood-passages is altered, 
occurs suddenly, is light in degree, and is not attended by marked 
symptoms ; it is due usually to shock or emotions. 

Hematogenous Jaundice. Jaundice is hcematogenous or non- 
obstructive when (1) the function of the liver-cells has been suppressed, 
as in acute yellow atrophy of the liver ; (2) when blood-destruction 
is in excess of the capacity of the liver to remove the product of 
destruction — the urobilin, as in certain forms of malaria, in perni- 
cious anaemia, in certain fevers, and other toxaemias. The onset of 
the jaundice is rapid, the general symptoms are more pronounced, par- 
ticularly the cerebral symptoms. They occur simultaneously with the 
jaundice. They are infectious, as in acute yellow atrophy of the liver 
and in Weil's disease. The toxic forms of haematogenous jaundice are 
not severe ; the discoloration of the skin is light yellow, and may not 



864 SPECIAL DIAGNOSIS. 

even be observed by the patient, nor cause pronounced symptoms. 
The blood is destroyed rapidly in these cases, and, as it cannot be 
disposed of by the liver, spleen, or kidneys, the transformed haemo- 
globin is deposited in the tissues. In this class of cases the urine 
contains but little bile-pigment, but there is a large amount of urobilin 
and indican. The stools are not clay-colored. 

Malignant or Infectious Jaundice. Acute Yellow Atrophy of the 
Liver. Acute diffuse inflammation of the liver, with necrosis of the 
cells, characterized by jaundice and cholsemia. Many of the cases 
occur during pregnancy. It is most common prior to the thirtieth 
year. It is said to follow fright. The symptoms are local and gen- 
eral. Jaundice is at first noticed after an attack of gastroduodenal 
catarrh. It is light, occasionally extends over the entire body, and is 
not usually attended by itching. After a continuance of these mild 
symptoms for from two days to two weeks, the patient complains of 
headache ; delirium sets in with stupor and convulsions. The headache 
is attended with vomiting. Fever of moderate degree begins at the same 
time, although in some cases it is absent. 

Although the jaundice is not intense, the effects upon the blood are 
early seen ; hemorrhages underneath the skin and from the mucous 
membrane take place. In pregnant women abortion follows, the hem- 
orrhage from which may be very excessive. The stupor and delirium 
are followed by coma, and death takes place in the first week ; or coma 
may be preceded by the typhoid state, and the disease lasts longer 
than a week. The urine is bile-stained, and contains albumin and. 
casts. It diminishes in amount, and is soon passed involuntarily. 
Lencin and tyrosin are always present. The latter may be seen in the 
sediment, although it is more marked when a few drops are evaporated 
on a cover-glass. The bowels are loose and the stools involuntary and 
clay colored. 

On examination the liver is found to be diminished in size ; this 
may not be appreciated by percussion in the anterior region, but in the 
axillary region the width is reduced one to two inches. There may 
be some tenderness over the liver and over the ducts. 

Diagnosis. The data upon which a diagnosis is based are the age, 
sex, pregnancy, the rapidity of onset of cerebral symptoms following 
jaundice, diminution in the size of the liver, with leucin and tyrosin 
in the urine. It must be distinguished from the jaundice of hyper- 
trophic cirrhosis of the liver, which at times becomes malignant. Some 
observers have thought that acute yellow atrophy may supervene upon 
this form of cirrhosis, thereby causing malignant jaundice ; but there 
is more fever than in atrophy, while leucin and tyrosin are not found 
in the urine. It must not be forgotten that all cases of jaundice may 
terminate suddenly with delirium, followed by coma, or by the develop- 
ment of the typhoid state. 

In phospl torus-poisoning the hemorrhages, the jaundice, and diminu- 
tion in the size of the liver are the same as in acute yellow atrophy. 
Gastric symptoms are more marked, and leucin and tyrosin are not 
present in the urine. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 865 

Weil's Disease. This infection, in which jaundice is the chief 
symptom, is considered in the chapter on Infectious Diseases. 

Yellow Fever. The account of the jaundice attending this infec- 
tion is found in the chapter on Infectious Diseases. 

Infantile Jaundice. Jaundice in infants is due to two causes : 
First, congenital obliteration of the ducts ; and, second, catarrhal in- 
flammation. It must not be confounded with the yellow discoloration 
of the skin, due to the excess of coloring-matter in the blood, which is 
not disposed of by the liver. 

In congenital obliteration of the gall-ducts jaundice rapidly ensues 
and deepens to an intense degree ; hemorrhages occur, the child be- 
comes stupid or comatose, may have convulsions, and death takes place 
in coma. There is rapid emaciation, and the liver and spleen are en- 
larged. The child may live many months. 

Simple catarrhal jaundice in infants is associated with moderate 
gastric disorder. The jaundice is light ; the conjunctiva? alone may 
be discolored. In infants malignant or infectious jaundice may be 
due to inflammation of the portal veins, secondary to umbilical phleb- 
itis. The jaundice develops after suppurative inflammation about the 
umbilicus, and is attended by fever. There may be some tenderness over 
the liver ; frequently peritonitis develops at the same time. Pysemic 
symptoms may set in, and pus may be found in other situations. If 
death does not ensue early the jaundice becomes more pronounced and 
causes cutaneous and mucous hemorrhages. Convulsions and coma 
are apt to supervene before death. Jaundice in infants also occurs in 
interstitial hepatitis of syphilitic origin. The evidences of hereditary 
syphilis are seen in the skin and mucous membranes. The liver is 
enlarged, and there may be tenderness from perihepatitis. 

Fever. Hepatic Fever. The occurrence of fever may be of diag- 
nostic importance in distinguishing the various forms of obstructive 
jaundice. Fever occurs frequently in jaundice ; but is significant in cer- 
tain forms only. In catarrhal jaundice it is present for three or four 
days only, disappearing as the severe gastric symptoms subside. It is 
probably toxic. In hepatic colic, with jaundice, it is transitory and 
associated with chills and sweats. In jaundice from obstruction it 
occurs when an infectious cholangitis, primary or secondary, arises. 
A peculiar type known as intermittent hepatic fever (see page 202) is 
often seen. The intermittent fever is associated with gallstones in the 
following groups : First, with each paroxysm of hepatic colic moder- 
ate fever and jaundice are present. The latter becomes more intense 
after each paroxysm, but disappears in a short time. The paroxysmal 
attacks may recur at intervals for years. Second, the hepatic colic is 
attended by distinct ague-like paroxysms of chill, fever, and sweat, 
after each of which the jaundice, which continues to the end, is more 
intense. Third, hepatic colic and gastric disturbance occur with fever, 
but without jaundice. The symptoms occur in distinct paroxysms. 
Gallstones are probably the cause in all these conditions, leading in 
some cases to chronic obstruction of the duct without infection. 

If an infectious cholangitis, with or without gallstones, is present, the 
symptoms are somewhat different, although the fever is of the same 

55 



SQ6 SPECIAL DIAGNOSIS. 

type. Thus (1) there is more tenderness in the hepatic region, with 
enlargement of the gall-bladder ; (2) the paroxysms are more frequent ; 
(3) jaundice is not so intense and not influenced by paroxysms ; (4) 
the patient is ill in the intervals, and there is wasting. There are no 
periods of improvement locally or in the general condition. The most 
important point in cases of gallstone is the subsidence of all symptoms 
between the paroxysm of fever. 

Intermitting fever of this character must be distinguished from 
malaria. The history of gallstones, with pain in the region of the 
liver, and the negative appearance of the blood, are sufficient to estab- 
lish the diagnosis. 

Hepatic fever also occurs in cancer when the neoplasms grow rapidly, 
in certain forms of cirrhosis, and in obstruction from other causes than 
gallstones. It is particularly common in suppurative inflammation of 
hydatid cysts, or after they rupture and discharge into the biliary 
vessels. Without previous knowledge of the hydatid cyst the diagno- 
sis is almost impossible, save that the pain is less when the obstruction 
is due to this cause than in obstruction from the passage of gallstones. 

Palpation. By palpation the lower border of the liver can be de- 
termined in thin subjects, or in those in whom the liver is greatly 
enlarged. It may be difficult to determine the border when the abdo- 
men is distended on account of flatulency. Careful palpation must be 
made with the tips of the fingers, pressing them firmly inward along 
the margin of the ribs, at the same time securing relaxation of the 
abdominal muscles by having the patient take a full breath, and 
having the legs drawn up and the shoulders elevated. The pressure 
should be made in the intervals following the act of inspiration. By 
care and patience the fingers can be pushed deeply inward and be 
made to feel the border of the liver, even in health. Care must be 
taken not to cause contraction of the right rectus muscle, for if this 
takes place the indurated mass may simulate tumor or enlargement of 
the liver. The left lobe of the liver, below the ensiform cartilage, 
extends half-way to the umbilicus. Here it is most accessible to pal- 
pation. By palpation we also determine the size of the gall-bladder 
and the degree of movement of the liver in respiration. On full in- 
spiration the liver descends, and during the act of expiration rises 
again. This movability is of service in distinguishing the liver from 
other organs that are fixed within the abdomen. 

In amyloid disease the lower edge is smooth, rounded, the tissue 
dense and unyielding to pressure, and the anterior surface perfectly 
smooth, as a rule ; but when the liver is also cirrhotic or syphilitic the 
surface may be irregular and fissured. 1 

The fatty liver has also a rounded smooth border, but its tissue is not so 
dense and resistant, except when cirrhosis coexists. Its surface is smooth. 

In single abscess the liver is enlarged, but not uniformly, and not 
invariably. If the abscess is located in the right lobe, and nearer the 
anterior than the posterior surface, palpation may be able to detect not 
only enlargement, but also deep-seated obscure fluctuation, surrounded 

1 See Mu^ser : "Amyloid Disease of Liver," Penna. State Medical Journal, 1899. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 867 

by a zone of hard tissue. The tumor is round, smooth, tense, tender, 
and painful. 

In multiple abscesses the liver is enlarged uniformly, and usually 
none of the abscesses are large enough to be felt as a distinct promi- 
nence. The liver is tender and painful. 

In hydatid tumor the degree of enlargement depends very much 
upon the situation of the cyst, upon its stage of development, and upon 
the activity of the echinococci. Sometimes the cyst is so small that 
its existence remains unsuspected ; at other times the enlargement is 
so great as to fill the abdominal cavity. As in abscess, the possibility 
of detecting the tense, globular, fluctuating, painless tumor character- 
istic of the disease depends upon its situation. If it is on the anterior 
surface or lower border, it is easily detected, especially if the tumor is 
at all large ; but if it projects from the posterior surface or from the 
upper or lateral borders, detection is difficult, and may be impossible. 

In congestion of the liver the enlargement is not so great as in ab- 
scess, nor are pain and tenderness so pronounced. Moreover, the 
enlargement is usually not permanent. The lower border, if it pro- 
jects below the edge of the ribs, is smooth. 

In hypertrophic cirrhosis the enlargement is moderate, the surface 
smooth, or but slightly roughened, denser than normal, and somewhat 
tender. 

In cancer the enlargement resembles that of single abscess and 
hydatid tumor in that it is irregular. But, unlike hydatid tumor, the 
irregularities are due to knobs or bosses which project from the sur- 
face of the liver, are usually entirely free from any fluctuation, and are 
tender on palpation. There may be a single large mass, or a number 
of knobs or nodules. The part projecting below the ribs may be free 
from any nodules. 

Palpation of the liver may discover a friction from perihepatitis, and 
pain or tenderness from that cause, or from cancer or abscess. Pidsa- 
tion of the liver may be a transmitted impulse from the abdominal 
aorta or a venous pulse, such as occurs also in the jugulars, from tri- 
cuspid regurgitation. 

Floating liver is diagnosticated by feeling in the lower, most fre- 
quently the right portion of the belly, a large tumor, which may, how- 
ever, easily be confounded with tumors of other organs. It can be 
distinguished as liver : (1) By recognizing the notch ; (2) by the pres- 
ence of a tympanitic note in the proper region of the liver, as loops of 
intestine lie between the diaphragm and liver ; (3) by the excessive 
movability of the tumor ; and (4) by the fact that it is possible to re- 
place the liver ; (5) by its size and consistency. It occurs almost 
exclusively in women, possibly as the result of a congenital lengthen- 
ing of the suspensory ligament, although more likely from relaxed 
abdominal walls. It may be confounded with ovarian cyst, appendi- 
citis with tumor, and movable right kidney with hydronephrosis. 

Constriction of the liver from tight lacing (Schnurleber) occurs chiefly 
in women. Tight corsets, and, still more, tight waist-straps or bands, 
squeeze the liver downward, especially the right lobe, so that it can be 
palpated. In more pronounced cases a furrow, often palpable, is pro- 



868 SPECIAL DIAGNOSIS. 

duced, and, below this, a constricted lobe which may extend as far 
down as the anterior superior spine of the ilium and cany the gall- 
bladder with it. In other instances, the right lobe is elongated, ex- 
tending even to the crest of the ilium. 1 

Lobes so depressed are usually thin and easily movable, and can be 
grasped with the hand and moved to and fro. If the lobe does not 
reach so far downward, it is more rounded and blunt in shape. It is 
not always easy to demonstrate its connection with the liver, because 
coils of intestine lying over the liver in the furrow make palpation diffi- 
cult, and cause a tympanitic note between the liver-dulness and the 
dulness of the constricted lobe. 

Confusion with tumors of other kinds can be avoided usually by 
deep palpation or percussion. 

Gall-bladder. When the gall-bladder has a certain degree of 
fulness, it may, according to Gerhardt, be not only felt in healthy 
persons, if the stomach and bowel are empty, as a smooth, round, fluc- 
tuating tumor at the lower border of the liver, but be even visible and 
be outlined by percussion. If a line is drawn from the right acromion 
process to the umbilicus, it will bisect the gall-bladder at a point where 
it passes over the margin of the ribs. The fundus is situated below 
the edge of the liver, at about the ninth costal cartilage, just outside 
the edge of the right rectus muscle. Palpation is easy when, owing 
to closure of the cystic duct, the gall-bladder is distended with bile or 
with inflammatory exudate, or enlarged by thickening of its walls or 
by an accumulation of gallstones. A pear-shaped tumor is then felt 
which, if not adherent to the border of the liver, is movable with it. 
In simple stasis, hydrops vesica? fellese, and purulent inflammation 
the tumor is tense and elastic ; in inflammatory or carcinomatous 
thickening of the wall, dense and irregular. Calculi can often be recog- 
nized by the form or hardness or by the sound made by rubbing them 
together. 

Aspiration. We are warranted in determining the nature of an 
obscure enlargement of the liver or of the gall-bladder by aspiration. 
In abscess, pus ; in hydatid disease, the characteristic fluid, may be 
withdrawn. 

In a case of local enlargement the apex of the swelling should be 
aspirated. If aspiration is performed near the upper border, the 
needle should be thrust downward ; if near the lower border, upward. 
The left lobe should be aspirated with care, in order that the stomach 
be not pierced. (See Aspiration in Diagnosis.) 

Auscultation. By auscultation we may detect a friction-sound in 
perihepatitis ; a grating or rubbing when the gall-bladder contains cal- 
culi if it is palpated ; a continuous murmur in tricuspid regurgitation. 

Percussion. The Size and Shape of the Liver. (See Plate 
XVL, Fig. 1.) Diminution in size can only be recognized by per- 
cussion. The normal extent of hepatic dulness is diminished. This 

1 Musser : Transactions Philadelphia Pathological Society, vol. x. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 869 

is usually more marked in the anterior and lateral regions. The 
diminution is due to simple or acute yellow atrophy of the liver or 
cirrhosis. It must not be confounded with the apparent diminution 
that takes place in emphysema, or that which occurs from distention 
of the bowels with flatus, as in peritonitis. Absence of hepatic dulness 
may occur when there is gas in the peritoneal cavity. When there is 
considerable distention of the intestines by gas, the anterior and lateral 
hepatic areas may be tympanitic. 

Enlargement of the liver is determined by inspection, palpation, and 
percussion. By percussion the size of the liver is accurately made out. 
Any marked increase of hepatic dulness beyond the normal limits (see 
p. 861) usually means increase in size of the liver. Both superficial 
and deep percussion most be performed. Palpatory percussion is of 
great advantage. 

The upper border is determined by percussing from a point above 
the liver-area toward the liver — anteriorly from the third interspace 
downward, laterally from the fourth, and posteriorly from the angle of 
the scapula. In health the upper border of the liver is found at the 
fifth interspace ; in the axilla, at the sixth ; and in the back, at the 
ninth interspace. Thence downward hepatic dulness should continue 
to the margin of the ribs. It falls short of this position by at least 
an inch in the aged, and in deep-chested persons it may not be more 
than two inches in width in front. The width of the liver-dulness in 
the right mid-clavicular line is about four inches, in the mid-axillary 
line six inches, and in the mid-scapular line three inches. 

Extent and direction of enlargement. The entire liver may be en- 
larged and of normal shape, or its outline may be irregular ; again, the 
enlargement may be limited to one lobe. Hence, the area of dulness 
may be increased in all directions, or the increase may be above or 
below the normal limit, if the normal shape is preserved. By percus- 
sion it may be found that the enlargement is regular from increase in 
size upward or downward, or increase in the area of dulness in both 
directions. On the other hand, if the enlargement is irregular, the 
liver-dulness may begin higher in the anterior region than in the axil- 
lary region, or may extend beyond the margin of the ribs in a limited 
area. When the enlargement is limited to the left lobe it is revealed 
by increase in the dulness from the xiphoid cartilage downward as far 
as the umbilicus. The entire middle region to the navel may be filled 
up by the enlarged liver. 

Uniform enlargement of the liver is due to congestion, hypertrophic cir- 
rhosis, fatty degeneration, amyloid disease, leukaemia, cancer, and some- 
times to hydatid disease and abscess. Enlargement of one lobe of the liver 
is due to hydatid disease, to abscess, or to cancer, in nearly all cases. 
Either the right or the left lobe may be the seat of such enlargement. 

Enlargement in one direction is due also to the three conditions just 
indicated. Although in abscess or hydatid disease enlargement down- 
ward is the more common one, it may be directly upward, the lower 
border of the liver occupying the normal position. When enlargement 
of the liver extends upward it is due to a cyst, or an abscess in the 
convex surface of the right lobe. 



870 SPECIAL DIAGNOSIS. 

Irregularity in the shape of the liver-dulness occurs in cancer, in 
abscess, and hydatid disease. Notwithstanding the apparent irregu- 
larity, enlargements of the liver conform to its usual outline, with but 
moderate variations, and always occupy the normal site of the organ. 

Diagnosis. Enlargement of the liver must be distinguished from 
enlargement of organs in contiguity with the liver, and from structures 
usually containing air, which have become solid or non-resonant. The 
enlargement must, therefore, be distinguished from pleural effusion, 
from disease of the lungs which causes dulness on percussion, or from 
disease of the abdominal organs causing increased dulness near the 
hepatic region. Hence, in renal tumors, in tumors of the large intes- 
tine or stomach, in ovarian tumors, in tumors due to accumulation of 
feces, the physical signs on percussion may simulate enlargement of 
the liver. 

Simulated Enlargement. It is well to bear in mind the conditions 
which simulate enlargement of the liver. Of these we have : 

1. Congenital malformation : the liver may be of abnormal shape, 
on account of which the area of dulness will be increased in a particu- 
lar direction. It may be quadrangular or rounded. The liver may 
be found in the right pleural sac in congenital diaphragmatic hernia. 
The increase of dulness upward will simulate enlargement of the liver. 
Congenital malformations may be suspected in the absence of any 
symptoms of hepatic disease, or of conditions which may cause other 
forms of spurious enlargement. Moreover, the increased dulness will 
have existed from early life. 

2. In rhachitis, on account of the malformation of the chest, the 
position of the liver may be such that its area will be increased. For 
the same reason the liver may be felt below the margin of the ribs. 

3. Disease of the spinal column causes dislocation, on account of 
which the liver may apparently be increased in size. 

4. Enlargement of the liver must be distinguished from pleural 
effusions. This is sometimes difficult. The symptoms of the pulmo- 
nary affection must be considered. The general conditions which 
cause hydrothorax must be borne in mind. The difficulty in distin- 
guishing the two arises because the dulness of each is continuous. In 
pleural effusion, however, there is uniform bulging of the affected side. 
The liver is not movable, the chest-expansion is lessened. The upper 
border of dulness of the fluid may be movable if the effusion is not 
large, while the line of dulness is S-shaped — that is, high behind and 
high in front. If the effusion is large, the upper limit of dulness is 
horizontal. The upper limit of dulness in the pleural effusion changes 
its position in many instances. In enlargement of the liver the lower 
ribs are often everted, but in pleural effusion a depression may be seen 
between the lower margin of the ribs and the upper surface of the 
liver, if the latter is dislocated by pressure of the fluid. Sometimes 
enlargements of the liver give rise to secondaiy pleural effusion, so 
that too often, after finding pleural effusion, the size of the liver is not 
estimated. 

5. Pericardial effusion and dilated heart are said to simulate enlarge- 
ment of the liver. The history of the case, the origin and mode of 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 871 

development of the symptoms, the physical signs of cardiac disease, 
point to its true nature. 

6. Enlargement of the liver may be due apparently to subdiaphrag- 
matic abscess. The history of the case is generally essential to a diag- 
nosis. The accumulation between the liver and diaphragm causes the 
latter to be pushed downward. It is very difficult to distinguish the 
spurious from the false enlargement in these instances. Aspiration 
may help in the diagnosis. 

7. Abnormal Condition of the Abdominal Parietes. Increased ten- 
sion or spasm of the recti muscles, giving rise to phantom tumors of 
the abdomen, simulate enlargement of the liver. They occur in young 
girls, and are associated with gastro-intestinal catarrh and symptoms 
of hysteria. Ansesthesia must often be employed to disperse the 
swelling. 

8. Tight Lacing. This may displace the liver upward or downward, 
according to the direction of the pressure. It may also, by exerting 
lateral compression, bring more of the liver into contact with the ante- 
rior abdominal wall. And finally, if the constriction has been by a 
strap or tight cord, a portion of the liver may be more or less detached 
and appear as a movable tumor. 

9. Some enlargements of the abdominal contents cause spurious en- 
largement of the liver. In the same way increased abdominal pressure 
(ascites, tympanites, etc.) causes the liver to rise higher than normal. 

a. The accumulation of feces in the colon. This causes continuance 
of liver-dulness downward, on account of which it may be thought 
that the patient has liver disease. A purgative must be given. 

b. An ovarian cyst. 

c. The presence of ascites. Exclusion of the latter is sometimes 
difficult, because the ascites may be loculated and situated in the hepatic 
region. It may give rise to symptoms of hepatic enlargement. Prob- 
ably aspiration alone can establish the diagnosis. Ordinary ascites 
should be easily distinguished by the physical signs and the result of 
exploratory puncture. 

d. Tumors of the omentum, chiefly tuberculous, may occupy such 
relation to the liver as to increase the dulness downward. The history, 
the occurrence of the omental tumor, with symptoms of tuberculosis, 
may aid in determining the true condition. 

e. In tumors of the kidney, which simulate enlarged liver, it is 
found that the edge of the liver cannot well be felt, but Murchison 
thinks the fingers can usually be inserted between the ribs and the 
upper part of the renal tumor. The renal tumor, however, is not 
fixed. It is rounded on every side ; it has the shape of a kidney. 
It may be associated with changes in the urine. 

/. Enlargements of the liver must be distinguished from pancreatic 
cyst, or effusion in the lesser peritoneal cavity. This can usually be 
accomplished with ease, except in hydatid disease of the left lobe near 
the suspensory ligament. In effusion in the lesser peritoneal cavity 
the tumor occupies the left upper quadrant, and may extend as low as 
the transverse umbilical line. It causes dislocation of the heart, so 
that the apex is as high as the third interspace, and beyond the mid- 



872 SPECIAL DIAGNOSIS. 

clavicular line. It is accompanied by an increase in the dulness pos- 
teriorly, so that the upper limit may extend to the angle of the left 
scapula. Puncture may furnish the necessary information. 

The presence or absence of pain may sometimes furnish a clue to 
the nature of the enlargement of the liver. Murchison considers this 
a reliable distinction. Painless enlargements of the liver are due to 
passive congestion, to hydatid disease, to fatty and amyloid disease of 
the liver. Painful enlargements of the liver are seen in abscess, cancer, 
and syphilitic disease, with perihepatitis. 

In children the lower border of the liver is normally lower than in 
adults, because the liver is itself proportionately larger. For the same 
reason the upper border is at a higher level. 

Enlargement of the Liver. Enlargement of the liver occurs 
in the congestions ; the acute inflammations, except acute yellow atrophy ; 
the chronic inflammations, except cirrhosis ; the degenerations, the 
morbid growths, and in hydatid disease. The physical signs have been 
considered seriatim in the pages immediately preceding. It must be 
remembered that the disease may occur without great changes in the 
size of the liver. The congestions have been considered in the previous 
pages. 

The remaining diseases of the liver will be considered in accordance 
with their pathological classification. After the congestions, we have 
the inflammations, then the morbid growths, then the degenerations, 
and, finally, hydatid disease. 

Abscess of the Liver. 

Two forms are seen : tropical abscess, so-called, in which one or two 
abscesses are found ; and multiple abscesses, found throughout the 
liver-structure. The single or solitary abscess usually occurs in the 
course of dysentery, and, in all probability, in the amoebic form only. 
A single abscess may also be due to traumatism, particularly in chil- 
dren. Multiple abscesses occur secondarily to inflammation somewhere 
in the portal area. Inflammation and abscess about the rectum, in- 
flammation of the appendix, ulceration anywhere in the gastrointesti- 
nal tract may be followed by multiple hepatic abscesses. The abscesses, 
however, do not occur directly by means of emboli, as in the case of 
amoebic abscess, but after inflammation of the portal vein or suppura- 
tive pylephlebitis. Multiple abscesses of the liver also follow obstruc- 
tion and infectious inflammation of the biliary passages {suppurative 
cholangitis). 

Tropical abscess or amoebic abscess varies in its clinical course. In 
a typical case the clinical picture is that of the general symptoms of 
suppuration setting in in the course of, or soon after, an exacerbation 
of amoebic dysentery, with local symptoms referred to the liver. 

Symptoms. The general symptoms are those of intermittent fever, 
paroxysms of which may occur daily or only every second day, attended 
by chill, fever, and sweat. The fever may be remittent or continuous. 

The complexion in tropical abscess of the liver is peculiar, as all 
writers upon tropical disease agree. The skin is sallow, 1 he complex- 



PLATE XL. 



Oedema J§ 

Tender- fj 
ness 1 




Abscess of the Livei 



fiq. 2. 



/ r 



,i 



M^v Mft^JI 



Hypertrophic Cirrhosis of the Liver with Enlargement 
of the Spleen. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 



873 



ion muddy, the face pale. Through this a slightly icteroid tint may 
be seen, and the conjunctivae are bile-tinged. Distinct jaundice is rare. 

The local symptoms. Pain in the region of the liver ; this may be 
referred to the region of the right or left lobe. It may be seated in 
the fifth or sixth interspaces anteriorly, or behind at the ninth and 
tenth ribs. There may be pain in the right shoulder. The pain may 
be paroxysmal, or it may be intense and persistent. 

The patient complains of weight and fulness in the region of the 
liver ; the enlargement causes some dyspnoea, and may cause cough 
and some vomiting. 

Fig. 201. 



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Intermittent fever in abscess of the liver. 



Physical Examination. (Plate XL., Fig. 1.) The liver is enlarged. 
The enlargement may be uniform ; if the abscess is central, the entire 
organ takes part in the swelling ; on the other hand, it may be an 
enlargement upward in the anterior, the axillary, or the posterior region. 
If the convex surface of the right lobe of the liver is affected, the en- 
largement is usually upward. If the lower portion of the right lobe is 
affected, enlargement extends downward, and the lobe of the liver can 
readily be detected on palpation. The mass may extend outward from 
the liver-edge. At first it is hard ; ultimately it softens and may fluctu- 
ate. If the abscess is limited to the left lobe of the liver, and is situ- 
ated about the suspensory ligament, the enlargement may be seen 
below the xiphoid cartilage. It may extend to the umbilicus and 
project forward. Sometimes it may be so large as to cause eversion of 
the ribs of each side, and render the entire epigastrium unusually 



874 SPECIAL DIAGNOSIS. 

prominent. The surface may become reddened. Over the tumor 
there is tenderness on palpation, and there may be, as in other situa- 
tions, fluctuation. (Edema of the surface is frequently seen. 

The irregular enlargement above mentioned is made out by percus- 
sion. The enlargement may be difficult to ascertain, on account of 
secondary pleural effusion, or secondary pleural inflammation, with the 
development of a hepato-pulmonary fistula, causing dulness posteriorly. 
If the case has been seen from the first, a friction-sound may be heard, 
followed by the physical signs of effusion. 

The appetite is lost, and nausea at the sight of food is pronounced. 
The condition of the bowels may vary with the state of the intestinal 
tract at the time of the hepatic complication. The dysenteric symp- 
toms may subside entirely or they may continue. Often there is only 
constipation, with the passage of mucus and hardened feces. In an 
obscure case the study of the stools should be made. The detection 
of amoebae in the mucus or in the feces may point to the true conclusion. 

Atypical cases are characterized by the absence of general symptoms, 
or the absence of local signs. Fever may be absent entirely, exhaus- 
tion alone being present, which could probably be ascribed to the pre- 
vious dysentery. Pronounced anaemia due to the dysentery may be 
associated, and even be the most marked symptom, as well as inflam- 
mation of the joints, or neuritis. In a case under my care the only 
symptom for a long time, with the exception of anaemia and loss of 
appetite, was severe pain in the sixth interspace. In other instances 
there are no liver-symptoms whatsoever. General symptoms of infec- 
tion, or an irregular, or even a continued fever, the cause of which 
cannot be ascertained, may alone be present. In one of my cases 
there was moderate continued fever, with loss of appetite and dyspeptic 
symptoms. There was no diarrhoea. No cause could be given for 
the fever, although it was noted that there was slight enlargement of 
the liver. The patient slipped out of the ward and went down to the 
yard to smoke ; on his return he was seized with an intestinal hemor- 
rhage which could not be checked and which resulted fatally. At the 
autopsy a large abscess of the liver was found, and there was ulceration 
of the rectum from which the intestinal hemorrhage took place. 

The diagnosis is usually not difficult in the typical cases. Under 
all circumstances attention must be paid to the facts bearing upon the 
etiology and the association of general and local symptoms. If the 
general symptoms of suppuration are present, malarial abscess may be 
mistaken for an intermittent fever. The result of an examination of 
the blood and of treatment by quinine Avould establish a diagnosis of 
malarial fever. It is difficult sometimes to determine whether the 
abscess is in the abdominal wall or in the liver proper, or whether it 
is situated beneath the diaphragm. If the liver is movable with respi- 
ration, the two former conditions may be excluded. An abscess in the 
abdominal wall is not influenced by respiration, and in subdiaphrag- 
matic abscess the movement is impaired. Suppuration of a hydatid cyst 
cannot be distinguished unless it has been known beforehand that a 
simple hydatid was present in the liver. Under such circumstances, 
if suppuration occurs, it is likely to be confined to the cyst. Abscess 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 875 

of the liver must be distinguished from gallstones, attended by inter- 
mitting fever without suppuration. While the distinction is difficult 
in many cases, yet the history of the case, the association of jaundice 
which deepens after each paroxysm, and the good general nutrition of 
the patient point to gallstones. Abscess of the liver is of shorter dura- 
tion than cholelithiasis, and its primary cause can usually be ascer- 
tained by examination of the rectum or the discovery of suppuration 
in other parts of the body. 

Exploratory puncture must be employed in many cases, and it can 
usually be done with safety. Puncture must be made over the region 
in which the enlargement is greatest, or at which the swelling is most 
prominent. In abscess secondary to dysentery a brownish-colored 
pus will be withdrawn, resembling anchovy sauce. It may be of a 
peculiar odor, and, on examination, amoebse common to this form of 
dysentery may be found. If there is no point of election, the needle 
may be introduced in the lowest interspace in the anterior axillary, or 
the seventh interspace in the mid-axillary line. A fairly large-sized 
aspirator should be used. Suppuration may be present, and yet not 
be reached by aspiration. 

Suppueative Pylephlebitis. Abscess of the liver may be due 
to pycemia. It may be a part of general pyamiia, or of portal pyaemia. 
Parasites and foreign bodies, as well as gallstones, may excite an ab- 
scess. The echinococcus cyst may suppurate, or round-worms may 
penetrate to the liver and cause suppuration. 

The symptoms of suppurative pylephlebitis and of pymnic abscess are 
general and local. Jaundice is more common than in solitary abscess, 
and there are greater pain and tenderness over the liver, which is uni- 
formly enlarged and tender. With the enlargement of the liver and 
jaundice we have the symptoms of pysemia. They are not peculiar. 
Sometimes the fever is distinctly intermitting, or it may be irregular 
and septic in character. 

The symptoms of solitary abscess of the liver, as has been previously 
stated, may be obscure, and attention be called to the liver only when 
symptoms arise due to a rupture into the neighboring organs. If per- 
foration takes place into the peritoneum, it is not likely that the cause 
can be established during life. The perforation frequently extends 
through the diaphragm to the pleura, and then to the lung. An em- 
pyema may be set up, the true source of which may not be ascertained 
unless the pus is examined. The physical signs are those of empyema 
— dulness or diminished resonance, absence of fremitus and vocal reso- 
nance, diminished breath-sounds, and impaired movement, together 
with symptoms of cough and dyspnoea. When the lung is infected 
the physical signs may resemble those of consolidation. We find dul- 
ness, bronchial breathing, and increased tactile fremitus. A harassing, 
convulsive cough occurs, and, sooner or later, expectoration of a red- 
dish-brown, brickdust-colored material which resembles anchovy sauce. 
This characteristic expectoration is decisive. It contains amoebse, and, 
in addition to blood-pigment and corpuscles, orange-red crystals of 
hsematoidin, cholesterin-plates, and leucin and ty rosin. When the 
abscess perforates into the stomach or bowel the discharge from either 



876 SPECIAL DIAGNOSIS. 

cavity may be of the above-mentioned nature. Perforation into the 
pericardium is usually followed by immediate death. 

Cirrhosis of the Liver. 

A diffuse interstitial inflammation of the liver, frequently with atro- 
phy of the organ, is caused, in the large majority of cases, by irritants 
which enter the portal circulation through the stomach. Of the irri- 
tants alcohol is the most common, and particularly the stronger liquors, 
as gin and whiskey. Other irritants, as spices used to excess, may 
likewise cause the diffuse inflammation. Cirrhosis of the liver may, 
however, be a sequel to the infectious diseases, notably scarlatina, and 
may be incited by malaria. The infectious forms of cirrhosis usually 
lead to atrophy of the liver. 

Another form is due to obstruction of the bile-ducts, with secondary 
overgrowth of the connective tissue. It is known as hypertrophic or 
biliary cirrhosis. In addition, cirrhosis of the liver may arise in the 
course of syphilis ; the histological characteristics are different from 
those of true cirrhosis. A secondary cirrhosis of the liver arises in 
the course of passive congestion of that organ, producing the so-called 
nutmeg-liver. 

Cirrhosis of the liver of the atrophic form, due to alcohol, presents 
various clinical features. In the first place, it may exist without 
causing any symptoms whatever during life. It may be found after 
death from other causes, or it may not present symptoms until an acci- 
dent occurs in the course of the disease, as hemorrhage from some por- 
tion of the collateral circulation. In both cases the symptoms are 
absent because the collateral circulation is complete. If this is incom- 
plete, however, grave symptoms, local and general, ensue. 

Before detailing them it may be well to state that the occurrence of 
one symptom, which we have termed accidental, may lead to the infer- 
ence that cirrhosis of the liver is present, particularly if the patient 
has been an alcoholic. This symptom is hemorrhage. It may be of 
the stomach, causing death at once or after repeated hemorrhages ; it 
may also take place from the intestine. 

The Symptoms of Cirrhosis. The symptoms are general, due to in- 
terference with the nutrition of the patient ; and local, their extent 
depending upon the degree of obstruction to the portal circulation. 
General symptoms rarely occur unless the local symptoms are present, 
as the latter cause malnutrition and mal-assimilation from interference 
with the gastro-intestinal digestion. 

The symptoms have been divided into those of the first stage, or 
stage of enlargement, and those of the second stage, or contraction. 
The so-called first stage is not always observed. 

During the first stage the symptoms are those of gastritis, with en- 
largement of the liver. The gastric symptoms are : morning retching 
or vomiting, with discharge of mucus, associated with other symptoms 
of gastric catarrh, as loss of appetite, nausea, tenderness in the epigas- 
trium, eructations, and constipation, with loss of flesh and strength. 
The liver is enlarged, but the outline is regular. 



PLATE XLI. 




V 




, &?■ 



Cirrhosis of the Liver with Ascites. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 877 

During the second stage more severe symptoms arise, due to obstruc- 
tion of the portal capillaries. The abdomen becomes distended and 
a sensation of weight and pressure is complained of. On examination 
ascites is detected. This may be enormous, causing monstrous disten- 
tion, with pouting of the umbilicus. The spleen is found to be en- 
larged, extending over twice or three times the normal area of per- 
cussion. If ascites does not interfere, the edge of the spleen can be 
readily made out The portal obstruction causes secondary gastro- 
intestinal catarrh, if it was not already present, on account of the alco- 
holism. Although constipation is usually present, there may be per- 
sistent diarrhoea, usually lienteric and occurring in the morning only. 
Hemorrhages may take place from the gastro-intestinal tract at any 
time, either from the stomach or the intestine. Not infrequently they 
occur from the oesophagus, due to varicosity of the veins at the junc- 
tion of the oesophagus and the cardiac end of the stomach. Hemor- 
rhoids are always present and may bleed at each stool. Jaundice is 
not the rule, and, if present, is usually light and due to the duodenal 
catarrh. The skin has a yellowish tinge or only a grayish earthen 
color. 

Physical Examination. (Plate XL., Fig. 2, and Plate XLI.) This 
may be rendered difficult before paracentesis is performed by the exten- 
sive ascites. The enlarged liver of the first stage will be found to have 
undergone contraction, although diminution in the area of dulness is 
not by any means as absolutely confirmative of contraction as the oppo- 
site condition is of hypertrophy. Percussion should be performed seve- 
ral times, because the distended intestinal coils may affect the results. 

With the distention of the abdomen enlargement of the superficial 
veins is also observed. This may be very pronounced, particularly 
about the umbilicus. The enlarged, swollen mass of veins in this situ- 
ation has been called, from its appearance, the caput Medusm. 

The general symptoms of cirrhosis, and particularly the symptoms 
of the later stages, are striking and diagnostic. The nutrition is much 
impaired. The patient, who, in the large majority of cases, had been 
corpulent, becomes emaciated. The skin changes in color and becomes 
of an earthy-gray or dirty sallow hue. The capillary venules of the 
face are dilated ; the distended capillaries on the nose are distinct. 
Later, ecchymoses may occur in the skin, and hemorrhages take place 
from the mucous membrane and into the retina. Debility ensues ; 
oedema of the ankles is almost sure to occur, and sometimes general 
anasarca may take place. It is extremely rare to have fever unless 
complications occur. The pulse is small and becomes more rapid than 
normal ; the heart-sounds grow weaker. The skin may be the seat of 
eruptions, and chronic skin diseases of various kinds develop. 

The urine throughout the disease presents no characteristics ; as 
ascites develops, it becomes scanty and dark, and loaded with urates 
and uric acid. In rare instances it may contain sugar, and, if the uric 
acid is in excess, albumin. 

Collateral Circulation. The collateral circulation that develops in 
order that the portal blood may reach the right heart takes place in 
various ways. First, communication may be formed between the veins 



878 SPECIAL DIAGNOSIS. 

of the mesentery and those of the posterior abdominal walls ; second 
between the coronary veins of the stomach and the veins of Glisson's 
capsule and the phrenic veins ; third, between the hemorrhoidal and 
the inferior mesenteric veins ; fourth, between enlarged veins occupy- 
ing the position of the obliterated umbilical vein in the ligamentum 
teres, and the epigastric and mammary vein. 

In the study of a case of cirrhosis of the liver a judgment as to its 
nature may be, in a measure, confirmed by the presence of other phe- 
nomena due to the same cause. Very frequently we have, at the same 
time, cirrhosis of the kidneys and sclerosis of the arteries, with second- 
ary atheroma, both of which have led to hypertrophy of the heart. 
Striimpell refers to the association of cirrhosis and chronic tubercular 
peritonitis. He thinks the former is the primary lesion which predis- 
poses to the development of the latter. The course of the disease is 
prolonged. 

The duration cannot be determined accurately, as the onset is usually 
insidious. After the ascites appears the duration may vary from six 
to eighteen months. Of course, this depends largely upon the com- 
pleteness of the compensatory circulation. Death usually occurs from 
intercurrent disease or progressive exhaustion. In not a few cases 
cerebral symptoms occur. In addition to the cirrhotic cachexia, the 
sudden occurrence of coma and convulsions, preceded by delirium, 
may ensue ; the cause of this is not fully known. It must be borne 
in mind that the occurrence of these symptoms in an alcoholic subject 
may be due to a cirrhosis, the presence of which had not been sus- 
pected during life. 

Diagnosis. The diagnosis is usually not difficult if the complete 
picture of the case is presented. It cannot be established positively 
without definite knowledge of the cause. If the patient comes under 
observation after ascites has developed, the diagnosis is more difficult. 
It must, in the majority of cases, be based upon exclusion of heart, 
lung, and kidney disease. A history of alcoholism and the presence 
of other symptoms of liver disease point to the hepatic origin of ascites. 
Ascites may be due to other causes within the abdomen, notably chronic 
peritonitis, exclusion of which is sometimes difficult. The general ten- 
derness, the less marked distention of the abdomen, and the absence 
of enlargement of the spleen point to peritonitis. The fatty cirrhotic 
liver may present symptoms similar to those of the atrophic form, 
except that it is enlarged. 

Hypertrophic cirrhosis, or so-called biliary cirrhosis, presents a 
somewhat different picture. In the first place, the cause is different. 
There is a history of gallstones, or obstruction of the duct from other 
causes. The liver is uniformly enlarged, and the surface is smooth 
and strikingly indurated. There are weakness and loss of appetite. 
Jaundice ensues very early, or may be the first symptom. It increases 
and persists throughout the course of the disease. Ascites is very slight 
or absent altogether. The enlargement and jaundice may continue for 
months or even years without the development of grave symptoms. 

Fever may, however, set in at any time, being in all probability due 
to the biliary obstruction. It is continuous ; the temperature rises 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 879 

to from 102° to 104° ; the tongue becomes dry and brown, the pulse 
rapid. All the symptoms of febrile jaundice ensue. The patient may 
be seized with convulsions in the course of the disease, followed by 
coma and death. Most authorities state that the enlargement persists 
throughout the course of the disease, but some observers say that after 
a long period of enlargement, with jaundice, contraction of the liver 
takes place, with symptoms of portal obstruction. Then the spleen 
may become enlarged and ascites take place, while the symptoms of 
digestive disturbances become more prominent. There may be ner- 
vous symptoms, due to acute, diffuse necrosis (acute yellow atrophy), 
setting in in the course of the disease. 

The diagnosis is often difficult. Gradual and persistent jaundice 
without cause, continuing for a long time, associated with persistent 
enlargement of the liver without symptoms of portal obstruction in 
the non-alcoholic subject, points pretty certainly to hypertrophic cir- 
rhosis of the liver. 

Syphilitic Disease of the Liver. 

Syphilitic disease of the liver may result in cirrhosis, or in the 
development of gummata. Syphilitic cirrhosis presents the same symp- 
toms as the alcoholic form. The history, the marked irregularity on 
the surface of the liver, and the existence of syphilis elsewhere may 
lead to a diagnosis of the true condition. 

In congenital syphilitic disease of the liver the inflammation is 
diffuse ; the liver is enlarged and hard ; the surface is smooth ; there 
are usually syphilitic lesions in other organs ; the patient presents 
syphilitic eruptions, and has the well-known wizened appearance that 
belongs to this affection. 

Syphilitic gummata in the liver may exist without presenting any 
symptoms whatsoever, or they may reveal their presence by pain and a 
localized swelling and discomfort, which call the patient's attention to 
the region, particularly if his general health is reduced at the same 
time. Tumors are situated in the left lobe, in the median line, or 
along the margin of the ribs. The pain is usually localized in this 
region, but may extend more or less over the entire liver, particularly 
if there is general perihepatitis along with other evidences of syphilis ; 
the latter are not always present, however. If the temperature is 
taken frequently, a moderate febrile range will be observed. It may 
not rise above 100 J°, but in the absence of other causes it is a valu- 
able diagnostic symptom. 1 In other instances the gummata may grow 
in such situation as to interfere with the portal circulation, or press 
upon the gall-ducts. The latter is very rare. If the gummata are 
felt, they appear as enlarged bosses which give the sensation of flat- 
tened hemispheres. Sometimes several separate elevations can be 
made out on the surface of the enlarged organ. To determine the 
exact nature of the lesion is often very difficult. The symptoms may 
conclusively point to hepatic disease. Knowledge of the presence of 

1 "The Diagnostic Importance of Fever in Late Syphilis." Musser: University 
Medical Magazine, October, 1892. 



880 SPECIAL DIAGNOSIS. 

syphilis aids in the diagnosis. If without a syphilitic history there 
are scars in the throat, nodes on the bones, or other signs of syphilis, 
the diagnosis will be tolerably certain. Severe pain is more promi- 
nent in syphilis than in cirrhosis, and the nodules of syphilis are very 
different from the granular surface of cirrhosis. 

The Fatty Liver. 

The symptoms of fatty liver are not marked. The physical sign is 
a uniform enlargement extending in all directions. On palpation the 
edges can be felt ; they are rounded and smooth. They are soft at 
first, but later become indurated. Fatty liver may be followed by 
cirrhosis after a period of alcoholism. The general symptoms are 
those of the primary disease. Fatty liver occurs in gouty subjects, 
but is notably present in wasting diseases, in tuberculosis, in chronic 
hip-joint disease, and in amyloid disease of the liver. 

Fatty liver sometimes follows the congestion of the liver which is 
present in the course of organic heart disease. It is not a true fatty 
liver, but a fatty cirrhosis. There is increased fatty degeneration with 
an overgrowth of connective tissue. This form is associated with heart 
and kidney disease. On palpation the edges of the liver are indurated. 
The liver may undergo diminution in size later, and the symptoms of 
cirrhosis ensue. 

Amyloid Disease of the Liver. 

Enlargement of the liver without pain is often due to amyloid dis- 
ease. Similar disease is found in other organs, and there is present, 
to point to the nature of the enlargement, syphilis, bone disease, pro- 
longed suppuration, or tuberculosis. In amyloid disease the pallor of 
the patient is great ; the face may be swollen, and the ankles slightly 
oedematous. The spleen is enlarged, the urine albuminous and abun- 
dant, but of moderate specific gravity. A history of syphilis is an 
important point in establishing the diagnosis. Fatty liver can readily 
be distinguished from amyloid disease by palpation. In the latter the 
surface is smooth, but very much indurated. 

Cancer of the Liver. 

The etiological factors upon which the diagnosis of cancer is based 
are : the age of the patient — most frequently between the fortieth and 
sixtieth year ; the female sex, in a measure ; and heredity. The dis- 
ease is nearly always secondary to cancer in some other situation ; 
consequently, in cases in which symptoms point to cancer of the liver, 
search must he made for the primary lesion elsewhere. The most fre- 
quent seat is the rectum, the uterus, the stomach, the remainder of the 
gastro-intestinal tract, the eye. The eye has been removed for obscure 
disease, and symptoms of carcinoma of the liver have subsequently de- 
veloped. The nature of the hepatic symptoms was obscure during life, 
but at the post-mortem examination melanotic sarcoma was found ; 
the primary lesion undoubtedly had been in the eye. Further etio- 
logical influences that may bear upon the diagnosis are : (1) The occur- 



PLATE XLII, 

FIG. 1. 






-^TU 



\\ 



\ /K>^ 



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yv\ 7 




K x v fl 



Carcinoma of the Gall Bladder with Involvement of the Live: 



t 




Enlargement of the Gall Bladder. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 881 

rence of gallstones, which act as the exciting cause in the development 
of primary cancer of the ducts, thence spreading to the liver ; (2) the 
occurrence of trauma. 

The symptoms of cancer of the liver may be due to (1) increase in 
the size of the liver ; (2) to pressure of the growths upon the ducts or 
terminal portal vessels ; and (3) to the general effects of carcinoma 
upon the system — the cachexia. 

Physical Signs. (Plate XXXVIIL, Fig. 2, Plate XL., Fig. 2, and 
Plate XLIL, Fig. 1.) The liver is enlarged and its surface irregular. 
The organ can be made out, by palpation, extending below the margin 
of the ribs. The edges are irregular, and, on the surface, bosses can 
be distinctly felt. In rare cases one or two masses only may be pres- 
ent, growing out of the substance of the left lobe of the liver, causing 
a large tumor below the sternum. The nodules are usually hard, but 
sometimes may be soft and even fluctuate. After emaciation becomes 
marked the nodules can be seen as well as felt near the surface of the 
skin, and their number distinctly made out. The abdomen is dis- 
tended. 

The liver is movable with inspiration. Progressive enlargement can 
be noted while under observation. The enlargement can be well de- 
fined by percussion, and, while the surface is irregular, the general 
shape of the dulness corresponds to that of the liver. The increased 
size and inflammation of the capsule cause a sensation of weight in the 
hepatic region and pain which may be intermitting in character. The 
nodules may be tender on palpation. The superficial veins are enlarged. 

In not every instance do we find enlargement. In some cases the 
cancer is associated with cirrhosis of the liver, or may itself be of a 
nodular type, and in the course of the disease undergo shrinkage. The 
liver is then normal or diminished in size, as indicated by percussion. 

The symptoms that attend cancer are : 1. Jaundice, which is not 
very deep unless the common duct is affected. 2. Ascites, Avhich is 
always present in the atrophic forms, but may be absent when the 
liver is enlarged. 3. The general symptoms are those of rapid emacia- 
tion, prostration, and, in some instances, moderate fever. Fever 
attends the rapidly-growing cases. It is usually continuous, but may 
be intermittent, especially if there is suppuration or suppurative in- 
flammation of the ducts. It is a well-known fact that gallstones are 
of common occurrence in patients suffering from cancer in any location 
whatever. The symptoms of biliary calculus or of obstruction may 
attend those of secondary cancer of the liver, and the stone has an 
etiological significance. 

In many instances secondary cancer of the liver may be present 
without symptoms to attract attention to this organ during life. If 
cancer in certain other regions has continued for the usual period of 
time, it is almost certain that at the autopsy cancer of the liver will be 
found to be present. 

Diagnosis. The diagnosis of cancer of the liver is not difficult when 
the changes in the liver can be made out on palpation and percussion. 
In rare instances, in which the liver is smooth, it may be mistaken for 
fatty or amyloid liver. A definite cause can usually be assigned for 

56 



882 SPECIAL DIAGNOSIS. 

the latter, while the occurrence of jaundice, the rapid increase in size 
of the liver, and the general symptoms of the cancerous cachexia indi- 
cate cancer of the liver. The syphilitic liver with irregular gummata 
may cause serious doubt ; the history of the case and other signs of 
syphilis aid in the diagnosis. Locally the condition may exactly sim- 
ulate carcinoma. The jaundice, however, is not so frequent in occur- 
rence, or so deep in syphilitic gummata ; the cachexia does not ensue, 
but the therapeutic test may be essential in order to make a diagnosis. 

In hypertrophic cirrhosis of the liver the jaundice is deep and the 
liver enlarged ; but there is little wasting or anaemia. The surface of 
the liver is smooth ; there are certainly no bosses, and the organ is 
painless. Ascites is more common in cirrhosis ; the patient is usually 
affected earlier in life than in cancer. 

In a large growing cancer one or two of the nodules may suppurate 
and simulate abscess of the liver. Abscess follows a definite cause 
usually, and occurs in middle life ; cancer is secondary to disease in 
other organs and occurs usually in late life. The results of aspiration 
differ in each. Moreover, a history of dysentery, the occurrence of 
pain, of profound anaemia, of pronounced hectic fever with irregular 
enlargement of the liver, but without jaundice or cachexia, point to 
abscess. 

Cancer of the liver may be simulated by cancer of organs in close 
proximity to the liver, as the pancreas, the pyloric end of the stomach, 
or the colon. In addition to the usual symptoms of pyloric cancer, it 
will be found that jaundice occurs late. Cancer of the pyloric end is 
not movable with respiration unless it becomes adherent to the liver. 
Cancer of the omentum and colon are not modified by respiration. The 
percussion-note over them is different ; they frequently extend beyond 
the liver-confines and are associated with symptoms of obstruction of 
the bowels. Fecal accumulation in the transverse colon must not be 
mistaken for cancer of the liver. The large masses adjacent to the 
liver may closely simulate cancerous nodules. In doubtful cases the 
colon should be emptied. Cancer of the liver and hydatid disease 
must not be confounded. The tumor in hydatid disease is usually 
single ; it is large, and may fluctuate or yield the hydatid fremitus. It 
causes irregular enlargement of the liver, when the tumor presents 
in the epigastrium or along the margin of the ribs. It is painless. 
Aspiration yields the characteristic hydatid fluid. 

Cancer of the bile-ducts cannot always be distinguished from cancer 
of the liver. Jaundice early in the course of the disease, in a person 
who has had gallstones, followed by enlargement of the liver and gall- 
bladder, in the absence of primary disease elsewhere, suggests cancer 
of the gall-bladder or ducts. This is more or less confirmed if the 
smooth and painless gall-bladder becomes hard, irregular, and tender 
on pressure. Cancer of the pancreas also presents difficulties ; a tumor 
in the mid-costal region, however, with vomiting and the early devel- 
opment of jaundice, before the liver has become enlarged or nodular, 
and associated with other characteristic symptoms, such as intestinal 
dyspepsia and fatty stools, points to the pancreas as the primary seat 
of the disease. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 883 

Hydatid Disease of the Liver. 

Hydatid disease is comparatively rare in this country, but, in my 
own experience at least, it is undoubtedly increasing in frequency. 
Without any increase in the opportunities for observation, I have 
seen seven cases within the last two years, compared to the same 
number during the five previous years. The disease occurs in people 
who live with dogs. It may occur at any age, but is most common 
in adult life. It is very rare before the fifth year. 

The symptoms are local, depending upon the size of the tumor. 
Small cysts may be present without any disturbance. Large and 
growing cysts cause signs of tumor, with great increase in the size of 
the liver. The physical signs depend upon the situation of the tumor. 
It may be found in the median line above the umbilicus, causing a 
distinct prominence, tense and firm, which sometimes yields fluctua- 
tion. Quite often the tumor grows at the suspensory ligament, pushing 
the diaphragm upward, dislocating the heart, and causing an increased 
area of dulness in the left upper quadrant. In this position it may 
simulate a pancreatic cyst or effusion in the lesser peritoneal cavity. 
If the tumor is in the right lobe, the enlargement of the liver may be 
upward or downward. The upper border of liver-dulness may begin 
two or three interspaces higher than normal posteriorly or in the axil- 
lary region. If the cysts are superficial, when palpated with the fingers 
of the left hand and percussed with the right, a vibration or trembling 
movement is felt, which may continue for a certain time. It is known 
as the hydatid fremitus. It is not always present. The enlargement 
is painless. Local sensations of weight and dragging may be complained 
of. If suppuration sets in, there may be a good deal of pain. 

The general symptoms are negative ; the nutrition does not suffer 
unless the enlarged mass interferes, by its pressure, with physiological 
acts of digestion and assimilation. If suppuration sets in, the general 
symptoms of abscess of the liver arise. Jaundice is more common than 
in tropical abscess. The abscess may perforate into one of the adjacent 
hollow viscera, or into the pleura and bronchi. It may perforate exter- 
nally. It may perforate into the pericardium or vena cava, and cause 
death. If perforation takes place in the biliary passages, obstructive 
jaundice arises, with secondary suppurative cholangitis. When the 
cysts rupture, or if they are aspirated, an eruption of urticaria may 
break out. This is not of diagnostic significance, except that it may 
point to rupture of the cyst. 

Diagnosis. The diagnosis is not difficult. The occurrence of irregu- 
lar, painless enlargement of the liver without general symptoms is sig- 
nificant. If fluctuation is detected, or the fremitus, a more positive 
conclusion can be reached. When suppuration takes place the symptoms 
are like those of abscess of the liver. Hydatid disease is to be distin- 
guished from syphilitic hepatitis, in which the enlargement is hard and 
irregular, and does not fluctuate. Sometimes the symptoms resemble 
cancer, but the age of the patient, the presence of jaundice, and the 
extreme emaciation and cachexia indicate that affection rather than 
hydatid disease. Enlargement of the gall-bladder containing a mucoid 



884 



SPECIAL DIAGNOSIS. 



fluid, in which fluctuation can be detected, may simulate hydatid dis- 
ease. The enlargement, however, may be preceded by conditions which 
cause obstruction of the cystic duct. The gall-bladder is movable. In 
some instances there may be resonance between it and the liver. It is 
usually of a pyriform or oblong shape. In hydronephrosis the symptoms 




Human echinococci. (From Finlayson, after Davatne.) 

A, a group of echinococci, still adhering to the germinal membrane by their pedicles. X 40. 

B, an echinococcus with head invaginated in the body. X 107. 

C, the same compressed, showing the suckers and hooks of the retracted head. 

D, echinococcus with head protruded. 

E, crown of hooks, showing the two circles. X 350. 

of a localized cyst are present. It does not move with respiration, as in 
hydatid disease ; it is attended by symptoms of renal disease ; explora- 
tory puncture is sometimes necessary to establish a diagnosis. A hydatid 
cyst is frequently confounded with pleural effusion of the right side, for 
there may be all the physical signs of effusion at the right base. The 

Fig. 203. 



$ f J 









^ 



Hooks from taenia echinococcus. X 350. 



distinction can be made by the character of the line of dulness. In 
hydatid cyst, as Frerichs points out, it is a curved line, the greatest 
height of which is found in the scapular region. It is not difficult 
usually to distinguish hydatid cyst from other forms of painless enlarge- 
ment. In fatty and amyloid disease the enlargement is uniform. Both 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 885 

occur more commonly in individuals of previous ill health, whereas 
hydatid disease occurs in healthy individuals. 

An absolute diagnosis of hydatid disease is based upon the results of 
exploratory puncture. When this is made over a tumor, or the centre 
of dulness, if it is due to hydatid disease, a clear fluid, slightly opales- 
cent, is withdrawn. The fluid is of a specific gravity of 1005 to 1009 ; 
it is of neutral reaction, does not contain albumin, but contains chlorides 
and sometimes traces of sugar. Hooklets may be found in the clear 
fluid. 

Diseases of the Gall-ducts. 

Pain and jaundice are symptoms of disease of the biliary passages. 
Pain may be constant or paroxysmal. If it occurs in mild degree, with 
tenderness and with jaundice, it is probably due to catarrh of the biliary 
passages. If severe, and in paroxysms with or without jaundice, it is 
due to gallstones. 

Inflammation of the Bile-ducts. This is due to inflammation and 
obstruction of the terminal portions of the common bile-duct. But few 
words are necessary, as it has been referred to frequently in speaking 
of jaundice. The symptoms are those of moderate jaundice, occurring 
coincidently with or following in a few days upon an attack of acute 
gastritis. The disease may occur in epidemic form. 

Gallstones. Gallstones form in the biliary passages, and may remain 
there without creating symptoms, or they may, by the efforts to pass 
them, cause attacks of pain called hepatic or biliary colic, after which 
the stone may pass into the intestinal tract without further hepatic 
symptoms. It may become impacted in the biliary canal and set up 
catarrhal or suppurative inflammation, which in turn may be followed 
by stricture. Gallstones usually form or at least show signs of their 
presence after the age of forty years, most frequently in women and 
in people who have led a sedentary life and partaken of rich and indi- 
gestible food. Individuals in different generations of the same family 
may be predisposed to them. 

Hepatic Colic. The passage of gallstones may be attended by a 
slight amount of pain only, which, unless in the right upper quadrant, 
would pass for an attack of simple indigestion. In the large majority 
of cases the pain is severe. The attack may be preceded by biliousness 
or indigestion for twenty-four hours, and moderate pains or a sense of 
weight and fulness in the liver. It frequently follows the taking of 
food. Ringing in the ears, disturbance of vision, or undue flushings 
are said to precede it in some instances. 

The attack may be sudden. The patient is seized with pain along 
the margin of the ribs of the right side, or there may be pain above 
the ribs, over the liver, and in the right shoulder at the same time. 
From the hepatic region it extends to the median line. Very fre- 
quently the pain begins and continues in the epigastrium. It may be 
most pronounced in this locality from the first. The pain is intense 
and paroxysmal. The patient is doubled up in agony. It causes more 
or less collapse. The pulse increases. Vomiting usually occurs at the 
same time, consisting first of the contents of the stomach, and then of a 



886 SPECIAL DIAGNOSIS. 

yellowish, bile-stained fluid. The vomiting may be extreme, so that 
the patient is tormented by the pain, the retching, and vomiting. The 
attack sometimes disappears as suddenly as it occurred, or wears off 
gradually. When most severe, symptoms of shock follow. The bowels 
are not disturbed during the attack. The urine may become suppressed ; 
it is usually high-colored, and after the attack may contain bile. 

At the time of the attack there is considerable tenderness below the 
xiphoid cartilage and in the hepatic region. The tenderness is more 
marked on deep pressure in the gall-bladder region and to the right of 
the mid-clavicular line, at the margin of the ribs. The epigastrium 
may be slightly swollen. The tenderness persists after the attack, 
and the stomach may be weak or irritable for some time ; pain, how- 
ever, usually disappears at once. The attack may recur frequently until 
the stone has been passed, so that in twenty-four hours the patient may 
have a dozen or more paroxysms. After the attacks have subsided 
light jaundice may supervene, which usually does not continue more 
than a Aveek at the furthest, during which there are also symptoms of 
mild gastritis. (See Intestinal Colic.) 

In some instances a chill precedes or immediately follows the pain, 
after which the temperature rises. After the paroxysm subsides the 
fever disappears rapidly, being followed by profuse perspiration. If 
the gallstones have set up catarrhal inflammation, moderate fever may 
continue for a few days. (See Fever in Obstruction.) 

Daring any paroxysm of hepatic colic it is desirable to determine 
whether or not a gallstone has been passed. This can only be done 
by placing the feces in a sieve and pouring water upon them until they 
dissolve. Instead of gallstones, dark-colored granular bile, which has 
become inspissated, is sometimes seen in the movements. Bile in this 
form gives rise to as much pain, according to Harley, as true biliary 
concretions. If the stone is not passed, it may fall back into the gall- 
bladder and cause no further symptoms for a time, or become impacted 
in the ducts. The impaction may be such that no obstruction is caused 
by its position, the bile being forced through or around it ; or complete 
obstruction may take place. (See Jaundice.) 

Obstruction of the Common Duct by Gallstones, (a) In addition to 
jaundice paroxysms of chill, fever, and sweat occur, with catarrhal 
inflammation of the biliary passages. (1) The paroxysms resemble 
intermittent fever ; (2) the jaundice may continue for years and deepen 
after each paroxysm ; (3) hepatic colic may occur with the paroxysm ; 
(4) the health fails but slightly. The paroxysms may occur daily or 
only once a week, or they may be tertian and quartan in type. The 
pain is referred to other situations than the gall-bladder or the epigas- 
trium. It is often relieved by vomiting or by certain positions of the 
body. The jaundice may be intermittent or remittent. On account 
of the obstruction in this situation the liver becomes enlarged. It is 
firm and smooth on palpation. The enlargement, as determined by 
percussion, is uniform. The gall-bladder is not enlarged. Fenger's 
thorough studies show that the intermittent phenomena are due to ball- 
valve action of a single stone. He also points out that emaciation is of 
common occurrence, (b) Gallstones may cause suppurative inflammation 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 887 

of the biliary ducts, just as suppuration of the gall-bladder may ensue. 
The symptoms, both general and local, are pronounced. The fever may 
be intermittent, but is more likely to be remittent ; jaundice is present, 
but it is constant in its intensity. The local signs of enlargement and 
tenderness are made out. The patients die of exhaustion or septicaemia. 
Sometimes the gall-bladder ruptures into the stomach or colon, and 
temporary abeyance of the symptoms may result. 

The Accidents of Gallstones. While these effects of the presence of 
stones in the biliary passages may rightly be considered as accidents, 
nevertheless their occurrence is so common as to be part and parcel of 
the history of gallstones. As accidents, we have most commonly the 
occurrence of localized peritonitis, which leads to dislocation of the gall- 
bladder, constriction of the duodenum, with secondary dilatation of the 
stomach ; we also have the formation of biliary fistula, with passage of 
the gallstone into the contiguous organs or channels. The stone may 
ulcerate into the gall-bladder from one of the ducts, may perforate the 
portal vein, or may perforate into the abdominal cavity — the most fre- 
quent accident. Perforation also takes place into the duodenum, into 
the colon, and, rarely, into the stomach. Such perforation can only 
be inferred from its secondary effects : (1) An attack of gallstones ; 
(2) local inflammation with fever ; (3) the occurrence of peritonitis, or 
the discharge of pus by the bowels, or by vomiting. That it is due to 
gallstones is proved in those rare instances in which the stone is passed 
per rectum. Often it may be impacted in the intestinal canal, causing 
symptoms of acute obstruction, or in the rectum, causing local tormina 
and tenesmus. The perforation, however, occurs in other directions. 
Sometimes fistulous connection is formed between the gall-bladder and 
the urinary passages, calculi and pus being discharged in the urine. In 
other instances fistulse between the bile-passages and the lungs are 
formed. The bile is coughed up and expectorated, sometimes with small 
calculi. In the most common form ulceration proceeds toward the sur- 
face, with formation of cutaneous fistula. After the fistula has opened 
externally gallstones in large numbers may be passed. If not, the 
cause of the fistula must be determined by the history and the results 
of investigation by probe, due attention being given to the condition of 
other organs. 

Enlargement of the Gall-bladder. (Plate XLIL, Fig. 2.) Enlarge- 
ment of the gall-bladder may be due to obstruction in the cystic duct. 
The liver is not secondarily affected. The enlargement is noted at the 
edge of the liver in the usual situation, and may gradually increase to 
an enormous extent, so that it has been mistaken for an ovarian cyst. 
The gall-bladder is often quite movable, and on account of its location 
and movability, as well as its long shape, has been mistaken for a float- 
ing or movable kidney. If the gall-bladder is not too large, it can be 
felt as a rounded or pyriform mass when the hand is placed along the 
margin of the liver, becoming more marked when the patient takes a 
full breath. The. enlargement is not attended by any other symptoms 
except mechanical ones, unless the contents of the gall-bladder are 
purulent. In obstruction with simple enlargement the fluid of the gall- 
bladder, should aspiration be performed, is thin, of a mucoid nature, 



888 SPECIAL DIAGNOSIS. 

and alkaline in reaction. It may contain cholesterin-plates, and some- 
times blood. It must be distinguished from the fluid of a hydatid cyst. 

Simple enlargement of the gall-bladder must be distinguished from 
enlargements due to inflammation. (1) Acute phlegmonous inflamma- 
tion of the gall-bladder may take place, attended by localized pain and 
tenderness, by high temperature, extreme prostration, and the rapid 
development of the typhoid state. Peritonitis rapidly ensues. It can- 
not be distinguished from other forms of acute inflammation in the same 
region, unless there was (a) a history of gallstones ; (b) tumor of the 
gall-bladder before the attack developed. (2) Suppurative inflammation 
of the gall-bladder may occur from gallstones and in infectious diseases. 
The colon bacillus, the diplococcus of pneumonia, and the typhoid bacil- 
lus give rise to infectious inflammation of the gall-bladder. The enlarge- 
ment takes place suddenly and may increase, the tumor becoming tender 
and painful on palpation. The direction of growth is toward the umbil- 
icus. The general symptoms are those of suppuration. Hectic fever 
or markedly remittent fever occurs, and, unless surgical relief is given, 
peritonitis ensues from infection or from rupture. This complication 
may be suspected from the occurrence of collapse and increase of the 
local symptoms. 

Either of the above forms of cholecystitis is attended by pain in the 
region of the gall-bladder or in the epigastrium or even as low down as 
the region of the appendix. The pain is severe and paroxysmal. The 
symptoms of bacterial infection, of which vomiting and fever are the 
most prominent, rapidly follow. The symptoms simulate appendicitis, 
intestinal obstruction, and pancreatitis. 

Enlargement, or tumors of the gall-bladder, usually due to cystic 
obstruction, as previously mentioned, may be mistaken for floating 
kidney, for tumor of the pylorus and for ovarian cyst. 

Tumors of the gall-bladder from any of the above-mentioned causes 
are recognized by their position and shape, and by the character of the 
tumor. The joosition varies. The usual site is in the gall-bladder 
region, but it may extend as low as the groin, or may be so large as to 
distend the ribs and fill almost the entire abdominal cavity. If, how- 
ever, the case has been under observation from the beginning, the tumor 
must have been found originally in the gall-bladder region. This region 
corresponds to the point of intersection of the border of the ribs by 
a line drawn from the acromion process of the right shoulder to the 
umbilicus, or in the direction of the foramen of Winslow. The tumor 
grows from this point toward the umbilicus in nearly all the cases. It 
can be recognized by its shape, which is pyriform, globular, or conical. 
The character of the tumor varies. It is usually tender and firm, but 
elastic on pressure, and movable. Fluctuation may often be detected. 
The septic gall-bladder is symmetrical and resistant to the touch. If 
the enlarged gall-bladder contains calculi, they may be felt as small, 
hard masses, which cause a grating sensation, to be transmitted to the 
finger. On aspiration, if the cystic duct is obstructed, the mucoid 
fluid previously mentioned, or pus, is withdrawn. If the common duct 
is obstructed, bile will pass through the trocar. 

The enlargement must be distinguished from tumors of the liver, 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 889 

stomach, duodenum, pancreas, or lymphatic glands. Tumors of the 
liver are usually due to carcinoma. They are multiple, associated with 
enlargement of the liver, with jaundice, ascites, enlargement of the 
spleen, and emaciation. Tumors of the stomach, duodenum, and pan- 
creas are in a different position, and are attended by functional disturb- 
ance of the respective organs from which they spring. An abscess of 
the liver, if purulent, may simulate enlargement of the gall-bladder. 
If the abscess can be palpated, an area of induration is first felt, fol- 
lowed afterward by softening and fluctuation of the swelling. In judg- 
ing of the true nature of the tumor we must bear in mind the causes of 
abscess. In hydatid disease the tumor develops slowly ; it is painless ; 
it may yield fremitus, and, if movable, the course is slow and not 
attended by general symptoms. Multilocular hydatid disease can rarely 
be distinguished save by the difference in position of the tumor. It is 
nodulated, hard, and tender, but is associated with jaundice, ascites, 
oedema of the legs, enlarged spleen, and great emaciation and prostra- 
tion, with rapid decline. A syphilitic gumma in the liver may occupy 
the region of the gall-bladder. It can usually be made out as continu- 
ous with the liver-structure. It is tender and painful, but irregular ; 
other signs of syphilis, or a history of the infection and of symptoms 
of a primary and secondary period, will aid in the distinction of the 
disease. 

Floating Kidney. The gall-bladder is larger and fixed at one end, 
whereas the entire kidney is movable. The gall-bladder may -fluctuate, 
and is associated with symptoms of hepatic disease. On the other 
hand, the well-known symptoms of floating kidney, the shape of the 
tumor, the sensation of nausea induced by palpation, point to the renal 
origin of the mass. Tumors of the kidney must be distinguished, such 
as sarcoma, hydronephrosis, and pyonephrosis. 1. There may be 
changes in the urine. 2. In renal tumors the intestine is in front of 
some portion of them, or a zone of resonance is found between the 
liver-dulness and the tumor. 3. Renal tumors are fixed. They may, 
as in hydronephrosis, come and go, preceded by attacks of renal colic 
and attended by anuria. From ovarian or uterine tumors the diagnosis 
must be made by examination of the genital organs, although with the 
former there is often difficulty. 

Enlargement of the gall-bladder on account of calculous obstruction 
must be distinguished from enlargement due to cancer of that organ. 
This is often difficult and cannot be done without having the patient 
under observation for a long period of time. Cancer of the gall-bladder 
is usually primary. It may begin in the gall-ducts. In the larger 
number of cases it occurs in patients who have had gallstones. It is 
found most frequently in females, and after the fiftieth year. Tight- 
lacing or pressure around the abdomen may predispose to it. The 
symptoms are pain, jaundice, emaciation, cachexia, and the presence 
of a tumor. The pain is localized and lancinating in character. Jaun- 
dice occurs in 70 per cent, of the cases, and gradually increases in inten- 
sity. The tumor is situated in the gall-bladder region, to the right of 
the umbilicus. It is hard or firm, painful, and the seat of tenderness. 
The tumor is fixed. Sometimes the disease is found in the cystic duct, 



890 SPECIAL DIAGNOSIS. 

and then the gall-bladder is enlarged. As the history of gallstones is 
of frequent occurrence in both instances, it is impossible to distinguish 
the two forms of obstruction causing enlargement, save that in carcinoma 
the emaciation and cachexia may point to the true nature of the case. 
In tumor of the gall-bladder due to cancer the secondary effects on the 
liver are usually more marked than in tumor from other causes. The 
liver enlarges and its surface becomes irregular or nodular. 1 

Diseases of the Spleen. 

Topography of Spleen. (Plate XXXV.) The spleen lies in the 
left upper quadrant beneath, and in contact with the diaphragm above, 
and below with the tail of the pancreas, cardiac end of the stomach, 
and suprarenal capsule. It extends transversely between the upper 
border of the ninth rib and the lower border of the eleventh rib, and 
from the middle axillary line posteriorly toward the spine. 

Palpation. An enlarged spleen usually retains the normal shape. 
The direction of the enlargement is downward and inward. It is access- 
ible to palpation in proportion to the degree of enlargement and of 
relaxation of the abdominal walls. It is movable with respiration. 
It cannot be said to be enlarged unless the edge is palpable at the end 
of deep inspiration, notwithstanding there may be increased dulness in 
the lower axillary region. When moderately enlarged, the smooth, 
blunt, rounded anterior surface and sharp edge of the spleen can be 
felt at the margin of the ribs, in deep inspiration ; when the enlarge- 
ment is great, as in leukcemia, the organ can be grasped with both 
hands, and its hilus clearly mapped out. The same thing can be done 
in the rare instances of floating spleen, but here a knee-chest position 
will favor successful palpation. The posterior border of an enlarged 
spleen can usually be made out by passing the hand backward over the 
resisting organ. At its posterior border a non-resisting space can be 
detected between the border and the mass of lumbar muscle. In chil- 
dren it is always easy to define this border. Xo such space exists in 
renal enlargements. The existence of this space and the direction of 
enlargement of the spleen are due to the costo-colic fold of peritoneum 
(Jenner). In splenic leukaemia the spleen may be larger after a meal, 
yield a creaking fremitus on palpation, a murmur on auscultation, and 
may even pulsate. The spleen may also lessen in size after diarrhoea 
or free hemorrhage. As it lies entirely behind the ribs, it does not, of 
course, admit of palpation when the size is normal. 

Percussion. (Plate XVI., Fig. 2.) Being a solid body it gives 
a dull sound on percussion, contrasting with pulmonary resonance 
above, intestinal tympany below, and stomach tympany anteriorly. 
Posteriorly and below its dulness merges into that of the lumbar region 
and kidney. The upper posterior portion is hidden behind the dia- 
phragm and overlapping lung, and hence is not accessible to percussion. 
Practically, therefore, the normal splenic dulness extends between the 
ninth and eleventh ribs, in the middle and posterior axillary lines, the 
spleen being there in contact with the ribs. 

1 Musser: Trans. Assoc. Amer. Physicians, vol. iv., 1889. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 891 

In percussion of the spleen the patient should lie on his right side. 
Beginning from above downward we percuss gently until pulmonary 
resonance is succeeded by dulness ; then anteriorly, proceeding toward 
the axilla, until stomach tympany yields to dulness. In the same 
way, percussing from below upward, the line is reached where intestinal 
tympany gives way to dulness. 

Splenic dulness may be encroached upon by the stomach or colon 
distended with gas, or its dulness may appear increased through disten- 
tion of the stomach and colon with solid matter, or by a left pleural 
effusion, or left basal pneumonia. The spleen may also be pressed 
upward by ascites or by a large abdominal tumor, so that its normal 
dulness is much lessened. 

If the ligament which holds it in place becomes relaxed, the spleen 
may become floating. According to Stint-zing, a floating spleen is 
increased in density, is generally enlarged, and is recognized by its 
form (notch, etc.), by being movable to and fro, and by the absence of 
splenic dulness in the normal position, and its reappearance when the 
spleen is replaced. 

Enlargement of the Spleen. Enlargement of the spleen may be 
acute or chronic. Acute enlargement occurs in certain infectious dis- 
eases, particularly typhoid fever, typhus, smallpox, relapsing fever, 
scarlet fever, diphtheria, epidemic cerebro-spinal meningitis, the mala- 
rial fevers and meningitis, and in diseases with blood-poisoning, as 
septicaemia, puerperal fever, and erysipelas. 

A rare cause of enlargement is acute splenitis. Generally, it is the 
result of emboli lodged in the spleen and starting from an endocarditis. 
The area of splenic dulness extends rapidly, and there is local pain 
and tenderness on pressure, increased by coughing and deep inspira- 
tion ; other symptoms are fever, nausea and vomiting, and occasionally 
delirium. If, as frequently happens in splenitis, emboli lodge in the 
kidneys also, the urine will be albuminous and bloody. If suppura- 
tion ensues, the fever becomes hectic, and the spleen continues to 
increase in size. Splenic abscess may, however, remain latent until 
rupture occurs. 

Chronic enlargement of the spleen occurs as hypertrophy and as the 
result of amyloid disease, leukaemia and pseudoleukemia, chronic mala- 
rial poisoning (ague-cake), syphilis, hydatid tumor, and cancer. En- 
largement is greatest in leukaemia and in ague-cake. The spleen in 
well-marked cases of these affections may reach to the umbilicus and 
even beyond, filling up the hypogastrium and extending to the right 
iliac region, measuring thirteen or fourteen inches in length and half 
as much in breadth, and proportionately increased in thickness. 

Primary splenic enlargement may occur (1) without local or general 
symptoms ; (2) anaemia, profuse hemorrhages, and brown pigmentation 
of the skin may be present with the enlargement. Hemorrhages are 
usually limited to the gastro-intestinal tract. The anaemia is of a chlo- 
ritic type, and there is no change in the leucocytes. (3) Enlargement 
may be associated with cirrhosis of the liver and jaundice, with gastro- 
intestinal hemorrhages and with ascites. This affection is commonly 
known as Banti's disease. The blood changes are almost a counterpart 



892 SPECIAL DIAGNOSIS. 

of those in progressive pernicious anaemia. It may be confounded with 
chronic inflammation of the peritoneum, giving rise to ascites and 
associated with mediastinal pericarditis. 

Diagnosis of Enlargement of the Spleen. (Plate XLIIL, 
Figs. 1 and 2.) Enlargement of the spleen can be distinguished from 
enlargement of the left kidney by the greater movability of the spleen. 

1 . The spleen does not extend as far back toward the spine as the kidney, 
so that the fingers can be thrust behind its posterior border, and, if the 
other hand grasps the anterior edge, the organ can be moved backward 
and forward. Splenic dulness extends to the ninth rib or higher. 
Kidney-dulness has no thoracic area, but reaches to the spine (lumbar). 

2. Again, the spleen is more movable with respiration than the kidney 
is. 3. The spleen falls further toward the median line, when the patient 
is in the knee-chest position, than does the kidney. 4. An enlarged 
kidney has the colon in front of it, and hence its dulness is obscured by 
the tympany of the bowel. 5. The shape of an enlarged kidney is more 
globular than that of the spleen. The anterior surface of the latter is 
smooth and rounded, but at its junction with the flat posterior surface 
there is a sharp edge. 6. Pain in renal disease often shoots down the 
ureters and into the testicles. In diseases of the spleen the pain is 
generally localized to the splenic region, and may shoot into the left 
shoulder. 7. Result of examination of the urine will often make clear 
that the disease is renal, or, by its negative result, will point to the 
splenic origin of the tumor. 

It is sometimes difficult to demonstrate enlargement of the spleen 
when the liver, and particularly the left lobe, are enlarged. Careful 
palpation reveals the edge of the spleen, which descends further than 
the liver in full inspiration. Having found the anterior edge, pressure 
with the other hand posteriorly will bring the spleen forward, which 
would not occur if the suspected enlargement was the left lobe of the 
liver. 

The diagnosis of splenic leukcemia (Plate XLIV., Fig. 1) rests princi- 
pally upon the blood-condition, particularly upon the existence of a 
marked increase of white blood-cells. Red cells are decreased, and 
altered forms are present. In addition to characteristic blood-changes 
there is a great disposition to hemorrhages ; dropsies and priapism are 
common ; and, in later stages, fever, diarrhoea, great weakness, and 
grave complications, such as pneumonia. Hemorrhage in splenic leu- 
kaemia occurs from the nose, bowel, stomach, gums, or kidney. It may 
also be subcutaneous, intermuscular, cerebral, or retinal. 

Regarding the diagnosis of splenic hypertrophy (ague-cake) in chronic 
malarial affections, Osier says : " The history of malarial cachexia, the 
absence of lymphatic enlargement, and the blood-condition will usually 
be sufficient for the purpose of a diagnosis. Great increase in the 
white blood-corpuscles is not often seen in the chronic splenic tumor of 
malaria ; indeed, they may be much diminished in number. Toward 
the end in very chronic cases the clinical picture may be very similar ; 
the large abdomen, possibly ascites, dropsy of the feet, and irregular 
fever may resemble closely splenic leukaemia, and the absence of an 
increase in the colorless corpuscles may be the only marked difference." 



PLATE XLII 



FIG. 1, 



FIG. 2. 




\ , 





Enlargement of the Spleen. 



Tumor of the Left Kidney. 



PLATE XLIV 



FIG. 1. 



—LI 







Mf 



MJ 



^ 



Leukaemia — Enlarged Liver and Spleen. 



FIG 


. 2. 




•■/*!'■:':■ 


^ s. 


. 




IB ^^^|r» 


, - ' ,/f \ •• ' 




.\^NN_ "" '' 






flN^>- 


>4fl^ 




^x c 


1 ■■'.' 




\ \ 





\j 



Cyst of the Pancreas. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 893 

Amyloid spleen, with enlargement of the organ, occurs in conditions 
of prolonged suppuration, especially when the bones are involved, and 
in chronic phthisis and syphilis. The spleen is enlarged, hard, and 
painless. The enlargement is rarely great enough to produce distress 
on that account, and it is so commonly associated with a similar condi- 
tion of the liver and kidneys, if not of other organs, that any constitu- 
tional symptoms produced by the spleen are apt to be masked by those 
produced by other organs. 

Hydatid tumor of the spleen rarely causes any symptoms except 
when it becomes very large ; then it may give rise to discomfort and a 
dragging pain in the left hypochondrium. But hydatid tumors of the 
spleen are only exceptionally very large ; when large enough to admit 
of palpation, and when the tumor is situated anteriorly or projects from 
the lower border or from beneath the organ, the detection of fluctuation, 
the withdrawal of the characteristic fluid by aspiration, and possibly 
the hydatid fremitus, will establish the diagnosis, when taken in con- 
nection with the gradual development of the tumor and exposure to 
possible infection. In the absence of physical signs of a cyst the nature 
of the tumor can only be suspected from the habits of the patient or 
his place of residence. Suppuration of the sac may be brought about 
by injury or rupture into the adjacent cavities, with grave if not fatal 
results. 

Inherited syphilis and chronic syphilis are accompanied by enlarge- 
ment of the spleen. They cause a chronic interstitial inflammation. 
The enlargement is not very great, and does not present characteristic 
features. 

Malignant tumors of the spleen are very rarely primary. The diag- 
nosis must be made by noting malignant disease elsewhere, the very 
rapid enlargement of the spleen, with possibly nodules scattered over 
its surface, and the presence of cachexia and the usual constitutional 
signs of a malignant disease. 

In young children enlargement of the spleen is not uncommon. It is 
found associated most frequently with rickets, syphilis, and malarial 
poisoning, and has been attributed to each of these diseases. In the 
London Lancet, April 30, 1892, Dr. J. W. Carr analyzes thirty cases, 
and comes to the conclusion that the enlargement of the spleen is due 
to splenic anosmia, the essential cause being unknown. Rickets, syph- 
ilis, and ague are found as passing causes only, since the disease is 
found in some cases where these causes can be excluded. According to 
this author, the disease is extremely rare in children older than two 
and one-half years. The spleen is more readily palpated in children 
than in adults. It is also more movable, and hence by bimanual pal- 
pation it can be more easily brought forward to the median line. 

Diseases of the Pancreas. 

Just as the functional activity of the pancreas is separated with diffi- 
culty from that of other functionally related organs, so the aberration 
of such activity is discerned with the greatest difficulty. As the physi- 
ology and pathology are blended so the symptoms are intermingled. 



894 SPECIAL DIAGNOSIS. 

The pancreatic secretion aids in intestinal digestion, particularly in 
emulsifying fats, hence symptoms due to disturbance of this function 
are looked for, and it is, in a measure, true of all cases of pancreatic 
disease that there is some intestinal indigestion. For the purpose of 
determining whether the function of digestion of fats has been modified 
the patient with suspected pancreatic disease is given fats in some form, 
and the stools are watched. If fat is passed in the stool in the amount 
taken by the mouth, without being broken up, or emulsified, it is held 
as proof that disease of the pancreas is present. While fatty stools may 
be indicative of pancreatic disease, the absence of fat in the stools, in 
patients who are fed upon it, cannot be considered to exclude disease 
of this organ, for, notwithstanding its absence in a large number of 
instances in which the experiment was tried, the pancreas was found 
to be the seat of grave disease. Sugar has been observed in the urine 
in many cases in which the pancreas was the seat of the disease. In 
fact, glycosuria has been attributed to pancreatic disease in cases of 
grave diabetes. This symptom, however, is not constant in pancreatic 
lesions. Three classes of symptoms — intestinal indigestion, fatty stools, 
and glycosuria — are, therefore, not diagnostic of pancreatic disease, but 
only afford presumptive evidence of its presence. 

Tumor of the Pancreas. The most striking symptoms of disease of 
the pancreas, apart from those due to the morbid process, as suppura- 
tion or cancer, are those due to a tumor pressing upon surrounding 
structures. It may press upon the gall-duct, causing jaundice. From 
its situation in the epigastric region it may resemble an aneurism, or a 
tumor of the pylorus or of the transverse colon. Tumors of the pan- 
creas are usually due to cancer. This is usually of the scirrhous variety, 
and generally primary. The enlargement cannot be distinctly made 
out unless the patient is very much emaciated. When it has advanced 
considerably it may simulate aneurism, but is distinguished by the 
difference in the character of the pulsation. In aneurism the pulsation 
is distensile, in disease of the pancreas it is an up-and-down movement ; 
the hand is lifted with each pulsation of the aorta. Tumor of the 
pylorus is excluded largely because of the more superficial position of 
the mass, because of its association with pyloric obstruction, and with less 
frequent jaundice than occurs in disease of the pancreas. A pyloric tumor 
is more movable and may change position after the stomach is inflated 
by gas or distended by fluid. Examination with the patient on the 
hands and knees may aid in the distinction between the two. In a 
tumor of the transverse colon its nearness to the surface and its mova- 
bility, its association with more or less constipation, and the occurrence 
of intestinal hemorrhage, are of diagnostic significance. 

The general symptoms of the cancerous cachexia ; the occur- 
rence of intestinal indigestion, or of fatty stools ; the gradual onset of 
jaundice ; the occurrence of deep-seated epigastric pain ; an immovable 
tumor, with glycosuria, make a symptom-group very characteristic of 
cancer of the pancreas. 

When the patient is on a milk-diet an examination of the feces will 
show that an excess of the ingested fat is lost — in short, that there is 
deficient pancreatic digestion with lessened absorption of fat. 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 895 

Hemorrhage. We owe to F. W. Draper and Prince our knowl- 
edge of hemorrhage into the pancreas. Since they have published the 
results of their labors the affection has been frequently recognized. 
The attack comes on suddenly in perfect health, and usually terminates 
life in a short period. Nothing in the occupation or conduct of the 
patient at the time is known to favor the development of the hemor- 
rhage. He is seized with severe pain, which is localized in the upper 
part of the abdomen. It increases in severity, and may intermit like 
colic. Nausea and vomiting take place almost at the same time. The 
vomiting becomes obstinate. Extreme depression rapidly sets in and 
the patient becomes anxious and restless. Collapse ensues in a short 
time. The extremities become cold and the forehead is covered with 
sweat. The pulse increases in frequency, and rapidly diminishes in 
strength. It soon becomes imperceptible. The pain and vomiting 
call attention to the upper abdomen. It is tender on pressure ; the 
tenderness may extend throughout the entire upper half of the abdo- 
men. Tympanites may develop. There is constipation in many cases. 
The temperature remains normal, or becomes subnormal. The pain, 
the vomiting, the anxious and restless state continue without relief. 

From the above group of symptoms it can readily be seen that the 
diagnosis is obscure. The disease can be taken for perforation of the 
stomach by ulcer, although the vomiting may not be so persistent and 
frequent. Intestinal obstruction in the upper portion of the tract 
presents allied symptoms. The hemorrhagic symptoms, however, are 
more pronounced in pancreatic hemorrhage. Pallor of the face is sure 
to ensue. The vomiting is not fecal in character. Constipation can 
be relieved. It is, however, difficult, and in many cases impossible, 
to establish a diagnosis. The rapidity of development of the symptoms 
is of importance. The pain and collapse may be due to rupture of an 
aneurism of the aorta. 

Acute Hemorrhagic Pancreatitis. For our knowledge of this 
disease we are indebted to Fitz. He collated the facts from the litera- 
ture, and, adding the results of his own valuable observations, has 
enabled us to recognize this affection during life. It usually occurs 
after the middle period of life, although it may occur in early child- 
hood, the youngest patient known to the writer being eight months of 
age. It is more common in males ; in those addicted to alcohol, and 
in. fat subjects. The patient has often been the subject of attacks of 
indigestion or of epigastric pain or of biliary colic. A blow on the 
abdomen or injury in the lumbar region appears to have been the 
exciting cause in a number of cases. 

The attack develops suddenly, resembling somewhat hemorrhage of 
the pancreas. There is violent pain which is at first complained of in 
the upper abdomen, although it is sometimes general. Nausea and 
vomiting are present in all the cases, constipation in most of them. 
The abdomen is frequently the seat of tympanitic distention. In 
many instances an obscure tumor can be made out in the lower epi- 
gastric region. Collapse-symptoms supervene, although fever may 
occur, the temperature rising to 102°. The cases terminate by the 
fourth day, even earlier in some cases. The pain and collapse are 



896 



SPECIAL DIAGNOSIS. 



probably due to pressure of the effused blood upon the coeliac plexus. 
The fever is due to a colon-bacillus infection. Violent delirium resem- 
bling acute mania and not unlike that seen in atropine-poisoning, occurs 
in some instances. Symptoms of localized peritonitis arise, and if the 
patient lives the tumor increases to a considerable size. 



Fig. 204. 




Tumor of the pancreas. 



The symptoms resemble acute intestinal obstruction, an irritant poison, 
or perforation of the gastro-intestinal or biliary tract. In several in- 
stances laparotomy has been performed for the relief of supposed 
obstruction. The intense pain in the epigastrium, with violent vomit- 
ing and distention of the upper abdomen, without a possible cause for 
obstruction, are favorable to acute pancreatitis. The difficulty of diag- 
nosis, however, is so great that resort to laparotomy is justifiable, in 
order to determine exactly the nature of the condition. In a most 
interesting case reported by W." S. Thayer, the diagnosis of acute 
pancreatitis (confirmed by laparotomy) was based upon the history of 
previous attacks of pancreatic pain, with fever, vomiting, and collapse, 
occurring in an adult, who was over-fat and an alcoholic ; the exclusion 
of disease in other organs and the absence of a history of gallstones or 
gastric ulcer or abscess from other causes ; the occurrence of pain ; the 
presence of a deep-seated tumor which gave indistinct signs of fluctua- 
tion, which was not movable with respiration, and the dulness of which 
was not continuous with or of the same character as that of adjacent 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 897 

solid organs. Epigastric tympany was also a point in favor of pancre- 
atic disease. The accompanying figure indicates the site of the tamor 
in Dr. Thayer's case. 

Suppurative Pancreatitis. Fitz has found that this affection 
occurs in adults under forty years, more frequently in males. Symp- 
toms continue during several weeks, and mav persist for a year. Pain 
in the epigastrium is complained of, associated with irregular vomiting, 
the latter persisting in spite of care as to feeding. Fever is irregular 
in type, and exhaustion ensues. Jaundice, fatty diarrhoea, and gly- 
cosuria have been met with in some cases. In a case under my observa- 
tion obstruction of the portal vein took place, with ascites. The latter 
was large, and recurred rapidly after tapping. In this patient pain 
and gastric disturbance were absent. There was no fever. Emacia- 
tion, constipation, and a tumor above the umbilicus were present; the 
emaciation was extreme. The tumor was ill-defined, painless, appar- 
ently superficial. Many other symptoms of pancreatic disease pointed 
out by Roberts were present. Apathy and despondency were marked ; 
bronzing of the face was also present. The patient was a middle-aged 
man, forty- two years old, addicted to the use of alcohol. He was 
thought to have cirrhosis of the liver. As happened in this case, the 
pus may accumulate in the duodeno-jejunal fossa and fill up the cavity 
of the lesser peritoneum, with more pronounced symptoms of tumor 
than occur in similar fluid accumulations in the above-mentioned cavity. 

Gangrenous Pancreatitis. This may follow later upon hemor- 
rhages into the pancreas. The symptoms are extremely obscure. Symp- 
toms of collapse may occur, following pain, which is of longer duration 
than in the acute form, or vomiting, which is not so persistent. A 
patient of mine, upward of sixty years old, suffering from dyspepsia, 
vomited blood in the course of an illness which was characterized by 
loss of flesh and weakness. The anaemia became very profound after 
the gastric hemorrhage, and exhaustion was extreme. There was no 
marked tumor, but only resistance in the region below the xiphoid. 
There were dulness and tubular breathing at the base of the left lung. 
Fever was absent. Death ensued from exhaustion. A small, flat car- 
cinoma was found in the pyloric end of the stomach, but there was no 
perforation. Gangrenous pancreatitis, with signs of an ante-mortem 
hemorrhage, was found. The accumulation took place behind the 
stomach and colon, but in front of the kidney ; its outer wall was 
bounded by the spleen. It was circumscribed above by the diaphragm. 
Pleuritis and small pulmonary abscesses at the base of the left lung 
were found. 

In some instances the pancreas has sloughed into the bowel, and in 
two such cases recovery took place after its discharge from the rectum. 

Chronic pancreatitis is not recognized during life, although its possible 
presence must be considered in all cases of diabetes, and in jaundice 
not otherwise explained. 

Cyst of the Pancreas. (Plate XLIV., Fig. 2.) Cysts of the 
pancreas follow impaction of calculi in the pancreatic duct ; sometimes 
the biliary calculi obstruct the orifice. The symptoms are those of 
tumor in the upper abdomen which occupies the median position, or is 

57 



898 SPECIAL DIAGNOSIS. 

chiefly on the left side in the upper quadrant. It may fill the abdominal 
cavity and simulate ovarian tumor. It usually develops slowly, but 
cases of rapid onset have been described. Fatty diarrhoea is not present. 
There is a sense of weight and fulness in the epigastrium. The cysts 
are not really true cysts, but accumulations of pancreatic fluid in the 
lesser peritoneal cavity. 

The signs are those of tumor to the left of the median line, encroach- 
ing upon the left lobe of the liver above, and extending almost to the 
transverse umbilical line. Korte, in a series of sixteen cases, observed 
that the greatest prominence of the mass was below the navel. The 
tumor is smooth, and may fluctuate ; it is not hard and tabulated. On 
account of its presence the diaphragm may be arched so that the heart 
is dislocated upward to the left ; the apex is found in the third inter- 
space. It also causes increased dulness behind on the left side, the 
upper border approaching the angle of the scapula. Exploratory punc- 
ture in either instance determines the nature of the fluid, and may deter- 
mine the diagnosis. Boas does not think the chemical character of the 
fluid is sufficient to establish a diagnosis. (See Examination of Cyst 
Fluid, page 367.) 

Senn has pointed out that in cysts of the pancreas the complexion is 
peculiar ; it is described as an unhealthy yellow, dirty, or earthy hue. 
The writer also considers that, in the diagnosis of pancreatic cyst, the 
history of the case, the location of the tumor, and its relation to other 
organs are to be considered. The disease occurs in adults, and usually 
follows traumatism. A blow in the epigastrium is a prominent ex- 
citing cause. In some instances it occurs after an attack of so-called 
biliary colic or colicky pains in the upper abdomen, with vomiting, 
but without jaundice — a condition characteristic of calculus in the 
pancreatic ducts. The growth of the tumor in some cases is unusually 
rapid — a point in favor of its pancreatic origin. It may attain an 
enormous size, as previously mentioned. 

In contrast to cancer, pain is absent. Fatty stools are absent. Pre- 
vious gastro-intestinal derangement may be ascertained upon inquiry. 
Diabetes, in this as well as other affections of the pancreas, may be 
present. The cyst is always found at first in the region occupied by 
the pancreas, depending somewhat upon the portion of the pancreas 
from which it originated. It may be below the right lobe of the liver, 
below the xiphoid, or in the left upper quadrant. In the great majority 
of cases it occupies the last situation. It displaces the stomach forward 
and to the right, the transverse colon downward, the diaphragm and 
the contents of the chest upward. The cyst may be movable in respi- 
ration. 

Diagnosis. It must be distinguished from cancer of the pancreas or 
adjacent organs, aneurism, hydatid cyst of the liver, the spleen, or the 
peritoneum, affections of the retroperitoneal glands, hydronephrosis, 
cystic disease of the suprarenal capsule, circumscribed peritonitis with 
exudation, ascites, cystic disease of the ovary. Pain is an important 
symptom of disease of the pancreas in its more acute manifestations ; 
it must be distinguished from the pain of intestinal obstruction and the 
pain of perforative peritonitis. The pain is always localized in the 



DISEASES OF LIVER, SPLEEN AND PANCREAS. 

region below the xiphoid, or, in general, is confined to the upper half 
of the abdomen. . It exactly simulates the pain of the affections just 
described. This resemblance is more pronounced because of the asso- 
ciation of vomiting and collapse in obstruction and perforative perito- 
nitis. Pain, although not so intense, but of a colicky nature, attended 
by diarrhoea or constipation, in some instances with intestinal hemor- 
rhage, may be due to calculous disease of the pancreas. Frequently 
this form of pain can be recognized if other symptoms of pancreatic 
disease, such as glycosuria, steatorrhea, and intestinal indigestion, are 
present. 



CHAPTER VII. 

DISEASES OF THE KIDNEYS. 

The kidneys are affected by disease from several sources. First, 
the great vascular supply is subject to the alteration which takes place 
in any large arterial area, either from direct hyperemia, through the 
influence of the vasomotor nerves (see Hyperemia), or from passive 
hyperemia or congestion through the central organ of the circulation. 
Second, the bloodvessels are the seat of thrombosis and embolism, particu- 
larly the latter, causing renal infarction. Third, infectious material, as 
micro-organisms or toxins, is carried to the kidney, and, in passing 
through the structure, gives rise to inflammation either of an infective 
or of an irritative character. Similarly, poisons that are ingested, and 
the products of metabolism, which, if modified in character or in- 
creased in amount, excite irritation and lead to inflammatory changes. 

But the kidney is open to attack from sources lower down in the 
urinary tract. Through the bladder and ureter infection may extend 
upward, causing the consecutive inflammatory processes which are often 
seen after disease of the urethra, bladder, or ureter. The kidney is at 
the apex of a system of tubes or channels. Any alteration of them, 
whether mechanical or functional, has a secondary effect upon the kid- 
ney. Obstruction of the ureter, or obstruction in the conduits beyond, 
leads to consecutive hypertrophy, inflammation, and atrophy. (See 
Morbid Processes.) If the urine is abnormal, one of these three 
causal conditions obviously may be present. 

The morbid processes which may take place in the kidney are such 
as are common to all organs — congestion, inflammation, degeneration, 
and morbid growths. The symptoms that attend the morbid processes 
are such as accompany similar processes elsewhere. The general symp- 
toms of the morbid processes are not marked except in the case of 
infectious inflammation or of morbid growths, as carcinoma. There are 
fever and emaciation. Fever occurs in acute nephritis, perinephritic 
abscess, suppurative and tuberculous nephritis, pyelitis, and, with twists 
of the ureter, in floating kidney. Emaciation occurs in chronic, suppu- 
rative, and tuberculous nephritis and carcinoma. Other general symp- 
toms in renal disease are due to the interference with the function of 
the organ which usually results. Pain is the only local symptom due 
to the morbid process ; a swelling the only physical sign. 

The symptoms of renal disease are also due to the functional or ana- 
tomical alteration of the kidney. But the structure is so closely inter- 
woven with the function that morbid changes in one imply morbid 
changes in the other. As the anatomical alterations are usually beyond 
the pale of physical investigation, we find that functional symptoms 
alone are apparent. Hence, we look for changes in the urine, which is 



DISEASES OF THE KIDNEYS. 901 

the product of renal function, and for symptoms resulting from abey- 
ance or cessation of the function. Rarely we have enlargements due to 
tumor, as cancer or abscess, or to obstruction of the channels, causing 
hydronephrosis, or to parasitic disease. 

The symptoms due to the alteration of function are : 1 . Urcemia. 
2. Cardio-vascular symptoms. 3. Ancemia. 4. Dropsy. 5. Altera- 
tions of the urine. 6. Alterations in micturition. The symptoms of 
renal disease are, therefore, both subjective and objective. 

The urine is not simply an index of the condition of the kidneys. 
It varies, within the bounds of health, in color, quantity, and quality. 
Food, exercise, and other conditions modify the secretion. It can 
readily be seen, therefore, that any general disease and many local dis- 
eases cause alterations in the character of the urine. Any abnormal 
urine, therefore, may be symptomatic of renal disease or of disease 
beyond the point at which the urine passes out of the body. Usually 
abnormal changes in the urine, due to the general condition, do not 
give rise to local renal symptoms or to abnormal renal function. The 
exception is seen when an excess of uric acid, or of urates, or of oxalates 
is passed. They may give rise to local pain and may set up sufficient 
irritation to cause albuminuria. 

Classification. The best classification of diseases of the kidneys is 
that based upon the propositions of Delafield, who, in a paper entitled 
" On the Diseases of the Kidneys Popularly Called ' Bright' s Disease/ " 1 
submitted a classification dependent upon the nature of the morbid pro- 
cess. The morbid processes included congestions, degenerations, and 
inflammations of the renal structure. In addition to these affections 
we must also include in the nosology of renal disease tumors (cancer, 
abscess, and hydronephrosis), and anomalies of growth or position 
(floating kidney, horseshoe kidney), affections due to invasion of the 
kidney by parasites, and affections due to obstruction of the tubes 
through which the offices of the kidney are carried on (renal calculus, 
hydronephrosis, and pyonephrosis). 

The Data Obtained by Inquiry. The Subjective Symptoms. 

The subjective symptoms are due to morbid processes within the 
kidney or to alterations of its function. The class of nervous symp- 
toms which belong to uraemia are subjective in character, as are also the 
symptoms of movable kidney. 

Pain. Pain, in the kidneys is referred to the loins. It is complained 
of as a dull aching, sometimes increased by movement, often attended 
by a sense of weight or pressure. Pain of this character extends over 
the entire lumbar region and is due to disease of both kidneys, as in 
acute nephritis. It is bilateral. We have also unilateral renal pain, 
referred to one kidney. The pain may be seated in the region of the 
kidney behind, opposite the two lower dorsal and two upper lumbar 
vertebral spines, or deep-seated in the abdomen, to the right or left of 

1 Trans. Amer. Physicians, vol. vi., 1891, p. 124. 



902 SPECIAL DIAGNOSIS. 

the spinal column below the level of the umbilicus. It is not generally 
mistaken for pain due to other causes, as myalgia, or disease of the 
vertebrae. If rnyalgic, it may follow exposure to cold and be associ- 
ated with pain in other muscles. Neuralgia of the kidneys no doubt 
occurs. It may be due to malaria, lead-poisoning, gout, or anaemia. 
It partakes of the character of neuralgia elsewhere. It must not be 
forgotten that in a case of disease of one kidney the pain is frequently 
referred to its healthy fellow. 

Unilateral pain may be constant or paroxysmal. Constant pain is 
usually due to organic disease of the kidney, as carcinoma or tubercu- 
losis. (See Palpation.) It may, however, be due to the impaction of a 
calculus in the pelvis of the kidney. It may also be due to a displaced 
or movable kidney. In tumors the pain may follow the course of the 
sciatic nerve, simulating sciatica. In pyelitis and hydronephrosis the 
pain is of a tearing character, whereas in movable kidney it is variable. 

Paroxysmal and lancinating pain, the paroxysms occurring at long 
intervals, is usually due to renal calculus, or to the presence of a foreign 
substance, as blood, in the pelvis of the kidney. The pain is seated 
not only in the regions just indicated, but extends along the ureter, 
from the loin to the front of the abdomen. It may persist for some 
time, at a point on either side of the umbilicus above or below it, or at 
a point on the surface of the abdomen opposite the brim of the pelvis. 
Thence the pain extends into the bladder, either above the pubis (the 
hypogastric region), or into the testicle, or down the inside of the thigh. 
It may be in the loin and at the end of the penis at the same time, or 
lancinate along the whole urinary tract. In rare cases the pain is in 
the kidney of the healthy side. The pain of renal colic is always asso- 
ciated with frequency of micturition, with or without pain during the 
passage of the urine. The character of the urine often points to the 
cause of the pain. The urine is usually bloody, and at first scanty ; 
when the obstruction is removed, it becomes copious. It sometimes 
contains pus. Between the paroxysms the urine may contain blood, 
pus, and pelvic epithelium. Renal pain or colic located in front of 
the abdomen must not be confounded with the pain of hepatic or intes- 
tinal colic. The pain is usually lower than in hepatic colic, extends 
along the course of the ureter, and is attended by symptoms referable 
to the urinary and not to the hepatic system. 

Nephrolithiasis (Renal Calculus). 

Renal calculi vary in size from " sand," through " gravel/ 7 to " stones.' 
The latter may be from the size of a cherry to one large enough to fill 
the pelvis of the kidney. They consist usually of uric acid, and are 
hard, brownish-red or blackish, crystalline, and the larger ones are 
arranged in distinct layers. More rarely we have calculi of calcium 
oxalate, extremely hard and nodular. Some stones have alternate 
layers of the two salts ; others consist of phosphates, but usually the 
inside is of uric acid or calcium oxalate, the phosphates having been 
deposited after the urine became alkaline. Very rare forms are of 
cystin, xanthin, indigo, etc. 



DISEASES OF THE KIDNEYS. 903 

A consideration of the frequency of the affection and some etiological 
data aid in the diagnosis. It is not a common affection. I have had 
twenty-nine cases in private practice and eleven in hospital practice. 
Thirteen cases only have been treated in the Presbyterian Hospital in 
twenty-five years, during which time over 8000 cases of all kinds were 
treated. 1 It is a disease of the middle and upper classes. This is par- 
ticularly true of uric-acid calculous disease. It is not a disease of the 
old or the very young, in my experience. The youngest subject was 
twenty-five years of age ; the oldest sixty-nine. The ages ranged from 
thirty-five to fifty-five. Twelve of my private patients were of the 
female sex, seventeen of the male sex. There does not seem to be much 
difference of frequency in the two sexes. Most authorities, however, 
hold to the preponderance in women, the ratio being as 3 to 1. Seden- 
tary occupation and an in-door life are predisposing. 

Symptoms. Symptoms may be wanting or they may be divided into 
three classes : 

(a) Calculi may remain in the pelvis of the kidney, and not cause 
any renal symptoms. They may cause gastric disturbance or catarrh 
of the bladder or renal pelvis. There may be occasional pain in the 
lumbar region, the cause of which is unsuspected. 

(6) They may excite pain, hematuria, and frequent micturition. 

(c) They may attempt to pass from the pelvis of the kidney into the 
ureter. They then cause renal colic, the symptoms of which have been 
described above. In the intervals of the attacks of colic the patient 
may be free from symptoms. 

The symptoms ascribed to the presence of a calculus in the pelvis 
of the kidney are pain, intermittent hematuria, pyuria, pyelitis, renal 
intermitting fever, acute orchitis, frequent micturition, and renal colic. 

Pain. Pain of the affected organ is the most constant symptom, 
and this pain is increased by movement, by jolting, and by pressure. 
Indeed, pain induced by pressure is of as great significance as sponta- 
neous pain. It frequently is persistent, and even continues in any 
position assumed by the patient. 

Pain in the region of the kidney occurs from renal hyperemia, neph- 
ritis, pyelitis, tumors, and malignant disease, or from myalgia of rheu- 
matic or other causation. Indeed, we have seen renal pain and hema- 
turia in a case of commencing appendicitis. The pain of renal calculus 
(not renal colic) comes and goes, and is more commonly intermitting 
and paroxysmal. Very frequently, however, it is constant and local- 
ized, either in the region over the kidney, or anteriorly in the region 
mentioned. In my experience it comes on during the day, and particu- 
larly the after part of the day, and not, as Jacobson would have us 
believe, at night. That it may occur spontaneously is not so much 
a peculiarity of renal calculus as that it can be excited by pressure, 
movement, etc. 

Pain is of more diagnostic significance in renal calculus than in any 
other renal affection. Every attribute that has been applied to pain 
belongs to the pain of renal calculus. Its very vagaries render its 

1 J. H. Musser: "Kenal Calculus," Philadelphia Medical Journal, 1898. 



904 SPECIAL DIAGNOSIS. 

presence one of the most valuable signs of renal calculus. Its behavior, 
however, is often like the flitting nerve-aches of hysteria, and we must 
see to it that this counterfeit is not passed upon us. Urinary phenomena 
do not serve for the distinction ; other neurotic manifestations or the 
stigmata of hysteria aid in the diagnosis. The pain may be aggravated 
by the function of menstruation and even bear close relationship to it. 

Hematuria. Hemorrhage from the kidney is the classical symp- 
tom of stone. It is the most constant and positive symptom of renal 
calculus. Prior to the use of the centrifugal machine, blood no doubt 
escaped the eye of the observer when in small amounts, partly because 
it was destroyed as the urine advanced in decomposition during the 
period it was set aside for the deposition of its solid elements, and 
partly because the fewness of corpuscles rendered them difficult to find. 
Excluding all causes outside of the kidney — i. e., of vesical and ureteral 
origin — renal hematuria may be due to congestion and inflammation, 
to infarctions, to new-growths, to tuberculosis, to renal calculus, and to 
parasites. The fevers and infections, and scurvy, purpura, leukaemia, 
and haemophilia are responsible for a number of cases. In six years 
2923 samples of the urine of 1997 persons were critically examined 
in my laboratory. Blood was present in 364 cases detected by micro- 
scopic examination alone. 

The hsematuria resulted from congestions or hypersemias (pregnancy, 
goitre, heart-disease, the fevers, infections, and jaundice) in fifty-six 
cases. In forty-two cases the hsematuria occurred in the course of 
acute and chronic Bright' s disease, and in nineteen more in arterio- 
capillary fibrosis, being either of renal or cardiac origin. Gastric dis- 
orders, rheumatism in many forms, gout, neurasthenia, and anaemia 
account for eighty-one of the cases, conditions always associated with 
the copious discharge of urinary salts, Avhich are irritating. Vesical 
disease accounts for seventeen cases, renal calculus for twenty-eight, 
and in twenty the diagnosis was not noted at the time and is forgotten. 

All the cases of renal calculus had hsematuria. It is not an inter- 
mittent phenomena alone, but one that is constantly persistent. 

It is necessary to eliminate all sources of urethral, vesical, and ureteral 
hemorrhage before coming to a conclusion that the hemorrhage is of 
renal origin. Cystoscopy must be resorted to, of course, and possibly 
in the right hands, ureteral catheterization. If the hemorrhage is free 
the time of its passage in the act of urination must be determined. The 
reaction of the urine must be borne in mind. It is true, catheterization 
alone can avail to pronounce from which kidney the hemorrhage comes. 

Blood-cylinders are rare, if present at all, in renal calculus. They 
denote hemorrhage from the renal substance. 

In a person of middle life with uric or oxalic acid tendencies, by 
virtue of heredity, occupation and habits, in whom no cause for the 
hemorrhage can exist in the urethra, bladder, or ureter, the chances 
are that it is of pelvic origin, due to the irritation of gravel or of urine 
densely loaded with salts. 

Klemperer * has recently called attention to hsematuria from healthy 

1 Deutsche med. Wochenschrift, March 4, 1897. 



DISEASES OF THE KIDNEYS. 905 

kidneys, as the result of overexertion, in one case from horseback 
riding, in another from the bicycle. He also reports four cases of 
haemophilia and a group due to an angioneurosis. Hyaline casts were 
not present, although blood-cylindroids were. General symptoms of 
neurasthenia support the diagnosis in the angioneurotic cases. 

Pyuria. Pus in the urine is looked upon by all authorities as 
almost essential to the diagnosis of renal calculus, but in my experience 
this product of inflammation is usually absent. Of the twenty-eight 
cases which I examined, in fifteen there was no pus ; in six a few cells 
or a very small quantity was found (four, womb cause obvious) ; in 
one it was noted as considerable (old gonorrhoea and syphilis, four 
examinations) ; in one a small quantity (male, cause assignable) ; in 
one it was small in amount, twice only in some fifty examinations ; 
in one it was abundant and due to genito-urinary infection as well as 
pyelitis. Pyuria is not present unless an accidental infection has taken 
place from the lower tract. 

Albumin. In twenty-one patients albumin was found. It was in 
large excess in three, due to coexisting Bright ? s disease. As a trace it 
is of frequent occurrence and does not imply a coexisting nephritis. 

Casts. Casts are present in the urine in nearly all cases of renal 
calculus. Sedimentation must be used. They are hyaline — not abun- 
dant — long and narrow. Their persistence without other kinds, with 
or without albumin, is diagnostic of renal irritation, and with other 
signs points quite unfailingly to calculus. 

The specific gravity of the urine is an aid in the diagnosis. Its 
persistence above the normal is both a comfort and a sign. It enables 
one to exclude renal cirrhosis and aids to eliminate hysteria or a renal 
neurosis. 

Frequent micturition is not in my experience an indication of 
stone in the kidney, save when attempts are made for its passage, 
although spoken of as a symptom of value by most authorities. 

Paroxysmal renal fever, allied to hepatic fever in its expres- 
sion, rarely occurs, but when present may be due to calculus. It may 
also be due to absorption of retained products, if the kidney is floating 
and becomes twisted. It may be due to pyelitis. 

Duration of symptoms and family history are also valuable 
data. 

Diagnosis. Middle life is a predisposing factor, and persistent 
hematuria is symptomatic, but pyuria rarely so, while albuminuria and 
hyaline casts in urine of high specific gravity are prominent elements 
of the symptom-complex upon which a diagnosis is made. 

The diagnosis can be established by the symptom-complex of pain, 
local tenderness, persistent hoematuria, albuminuria, and easts (the cardiac, 
vascular, and nephritic origin of which is excluded), by the phenomena 
of renal colic and by passage of fragments of stone. 

If the hemorrhage persists after prolonged rest, it is more likely of 
cancerous or tuberculous origin. 

The differential diagnosis must be made from appendicitis, movable 
and twisted kidney, biliary colic, and other affections simulating these. 
Catheterization and exploration by the ureter are required in many 



906 SPECIAL DIAGNOSIS. 

cases. Hollander believes we can in a large number of cases make a 
diagnosis without the aid of catheterization, and fears the danger of 
infection from below. 

Kelly, very skilfully after ureteral catheterization, aspirates the 
ureters and thereby brings down fragments of calculi. He also explores 
the ureters with hard-rubber bougies tipped with wax. He can deter- 
mine the presence of calculi by the markings on the tips of the bougie. 

Frequency of Micturition. There are four causes of frequent 
micturition : (1) Disease of the kidneys, the ureters, or the bladder ; 
(2) an increase in the amount of urine, as in diabetes ; (3) concentra- 
tion of the urine, as in fevers, gout, or acute nephritis ; (4) a reflex or 
pure neurosis. 

Increased frequency of micturition occurs in almost all organic affec- 
tions of the geni to-urinary system. It is seen in all forms of congestion 
and inflammation of the kidneys. In some forms of nephritis the 
increased frequency may be due to increase in the amount of urine as 
well as to increased sensitiveness of the organs. In chronic nephritis 
it may not be noticed, save that the patient is called upon to pass 
urine at night, arousing him from sleep for this purpose. Disease of 
the ureter and disease of the bladder are also associated with this 
troublesome symptom. It occurs in its most aggravated and charac- 
teristic form in renal calculus, or when any foreign substance is 
located in the ureter or bladder. The frequency amounts to six, eight, 
or even a dozen times in an hour. It is often associated with tenes- 
mus, the patient having a constant desire to urinate, but passing small 
amounts. This form of tenesmus is more frequent when the bladder 
or urethra is the seat of disease, and in renal calculus. 

The Data Obtained by Observation The Objective Symptoms. 

The data obtained by observation are secured : 1. By physical exam- 
ination of the kidney. 2. By an examination of the urine. 3. By 
catheterization of the ureters. 4. By a skiagraphic examination. The 
examination of any person who is sick is not complete without an 
examination of the kidney and of the urine. The third and fourth 
methods of examination are not necessary unless the subjective symp- 
toms indicate their necessity, or general symptoms are not otherwise 
explained. 

Topography of the Kidneys. (Plate XIII., Fig. 2.) The kid- 
neys are situated in the right and left lumbar regions respectively, the 
left being a little higher than the right. They extend from the eleventh 
rib, or twelfth dorsal vertebra, to the third dorsal vertebra. The left 
kidney is in contact above with the spleen, and the right with the liver. 

Palpation and Percussion. The kidneys are enveloped in more 
or less abundant fat ; their distance from the anterior surface of the 
abdomen renders them inaccessible to percussion from that direction, 
and the thick dorsal and lumbar tissues, coupled with the relation of 
the kidneys with the organs, spleen, and liver, which give a dull note 
on percussion, make it difficult to outline the kidneys from behind. 

Palpation of the normal kidney is difficult. It can only be bimanual. 



DISEASES OF THE KIDNEYS. 907 

Place the fingers of one hand below the last rib outside of the lumbar 
muscles — erector spina? — and apply the other below the ribs in front. 
Firm, persistent pressure with the abdominal muscles relaxed, especially 
in thin subjects, will often enable the normal kidney to be felt. 

Palpation of the kidney becomes easy when it is either enlarged or 
displaced. In the case of an enlarged kidney the patient should lie 
upon his back or be slightly turned to the opposite side ; one hand is 
placed beneath the kidney and pressed upward, while the other is pressed 
firmly and steadily from above, or laterally toward the kidney. In this 
manner the kidney can be grasped between the two hands, its size esti- 
mated, and its physical characteristics as regards hardness, softness, 
fluctuation, and mobility determined. Enlargements are also detected 
by palpation of the abdomen. (See Palpation of the Abdomen.) The 
fact that the tumor moves a little with respiration aids in its detection ; 
and if it is unusually movable the edge of the hand can be slipped 
above its upper end, by turning edgewise that border of the hand 
which is adjacent to the ribs. A renal tumor is usually two or three 
inches to either side of the median line, a little above the transverse 
umbilical line. 

A very favorable position for palpating movable kidneys is that 
assumed by standing and leaning forward over a chair, with the trunk 
supported by the hands resting on the seat of the chair. In this 
position the abdominal muscles are relaxed and the kidneys fall for- 
ward. 

In the diagnosis of renal tumors, in general, it should be borne in 
mind that they are slightly movable with respiration unless adherent, 
as in malignant disease, abscess, and cysts. Unless too large they pre- 
serve their reniform shape, and press in front of them the ascending or 
descending colon, whereas ovarian tumors lie in front of it. The posi- 
tion of the colon should, therefore, always be ascertained, and to this 
end it may be necessary to innate it. 

Percussion. The best results are obtained by having the patient 
lie face downward, and placing a cushion under the belly, so as to make 
the lumbar regions a little more prominent. Strong percussion is 
required, and an artificial plessor and pleximeter are to be preferred. 
Percussion should be conducted with a view to marking the angle 
which the liver-dulness and splenic dulness make with that of the kid- 
ney on the right and left sides respectively. The kidneys extend below 
the lower lines of liver and splenic dulness, and laterally for a width not 
greater than four inches. The difficulties in the way of outlining the 
kidneys by percussion are greatly increased in persons with much flesh, 
or when the abdominal walls are waterlogged, as they become in ascites, 
and it is practically impossible, under such circumstances, to be sure of 
the boundaries of the kidneys. The colon must be emptied to yield 
trustworthy results. 

Movable Kidney. 

Movable kidney is usually seen in women after the age of forty years, 
who have done physical work or have had many children. Adult 
males and single women do not escape. Its occurrence is frequently 



908 SPECIAL DIAGNOSIS. 

preceded by a history of unusual lifting or strain, followed by tearing 
or dragging sensations in the abdomen. Pain may continue for 
several weeks after the injury, and then subside and the occurrence 
be forgotten, or subjective sensations may continue. In other in- 
stances the movable kidney is a part of a general visceral displace- 
ment. Gastroptosis and gastro-enteroptosis can usually be made out in 
such cases. 

The symptoms that arise are due to the local dragging or pulling of 
the kidney on its bloodvessels and nerves, or to reflex symptoms, or to 
pressure upon adjacent organs. 

The pain that attends movable kidney is usually referred to the 
right or left of the median line ; sometimes to the hypogastrium . It 
may be constant, dull, and aching in character. Paroxysms may arise 
in the course of the constant pain, or a paroxysm alone may take place. 
The paroxysms continue for three or four days, during which time 
other subjective symptoms are more pronounced. The attacks are 
known as DietVs crises. Nausea may attend the paroxysms, or be more 
or less constant. Sometimes vomiting takes place. The great pain is 
associated with swelling and tenderness of the kidney. The pain, 
vomiting, and local tenderness may simulate peritonitis. 

In addition to pain a dragging sensation is experienced ; the patient 
may be aware of the presence of a tumor or lump in the abdomen, and 
also of its movability. The reflex symptoms are chiefly referable to 
the nervous system. Emotional disturbance is observed when the 
organ is displaced. Hysteria may be present. Palpitation of the heart 
is a common reflex symptom. There are often depression of spirits 
and hypochondriasis. Jaundice may occur from pressure, and the intes- 
tine may be occluded. 

The urinary symptoms are of interest. When the local pain and 
other symptoms are more pronounced the urine may be scanty. In 
one case it was reduced to sixteen ounces in twenty-four hours. At 
the same time that the urine is scanty hydronephrosis will develop. It 
will be referred to again. As the kidney slips back into its bed the 
twisting of the ureter is relieved, and copious discharges of urine take 
place. 

Objective Symptoms. (Plate XL V., Fig. 1.) The abdominal walls 
are usually relaxed, and may or may not contain a large amount of fat. 
Movable kidney is best detected by palpation. The patient should stand 
with the body bent forward and the hands resting on a chair, as de- 
scribed above. The organ is recognized by its rounded borders, its 
bean shape, its movability, the detection of the hilus and perhaps of the 
pulsation of vessels in it, and by the fact that it can be replaced. Pal- 
pation causes a sickening feeling, analogous to that experienced when 
a testicle is compressed, but less in degree. Percussion will, however, 
demonstrate that a body, supposed from palpation to be the kidney, is a 
solid organ. The tumor can be found to the right or left of the median 
line, freely movable and changing its position with that of the patient. 
If the tumor is situated on the right side, it may be in close proximity 
to the liver, or be felt opposite the umbilicus, or often in the iliac region. 
When near the liver, by careful palpation the fingers can be introduced 



PLATE XLV. 



FIG. 1. 




^ 



Movable Kidney. 



FIG. 2. 



. \ 






■v. 



\Sk / 



Mf 



^ 



Sarcoma of the Right Kidney. 



DISEASES OF THE KIDNEYS. 909 

between the border of the liver and the mass. Usually it does not 
move with respiration, but sometimes it is found to do so. On the 
left side it may be as high up as the margin of the ribs. It is gener- 
ally felt in the mid-clavicular line, a little above the level of the umbil- 
icus. 

In a case recently under the writer's care the woman, aged fifty-five 
years, would experience pain in the abdomen about once a month, to 
the right of and above the umbilicus. At times nausea and vomiting 
accompanied the attacks, at other times marked depression or hysteria. 
Anuria always occurred and continued for a variable time, not longer 
than five days. With one of the paroxysms a tumor was found in the 
region of the gall-bladder, movable with respiration, but distinctly 
defined from the liver by placing the fingers between the lobe and 
kidney. It moved with each change of position of the patient, and at 
first the hilus could be distinctly felt. As the pain continued the 
anuria persisted, and a marked change in the tumor was observable. 
It gradually increased in size, and a portion of it fluctuated ; it was 
round and partook of the character of a cyst. The fluctuation was de- 
tected by placing the hand on the tumor in front and pressing firmly 
toward the other hand placed in the loin above the pelvis. After sev- 
eral days a copious discharge of urine took place and the swelling 
subsided. 

Movable kidney may be confounded with tumor of the gall-bladder, 
tumor of the pylorus, and with tumors in the pelvis. It is not likely 
to be confounded with an omental tumor, carcinoma, or tuberculosis, 
because the phenomena of these processes are not present and ascites 
does not occur, nor is there rise of temperature, as in many cases of 
tuberculosis. As pointed out by Henry Morris, tumor of the gall- 
bladder and movable kidney are frequently of conjoint occurrence. 
Movable kidney is distinguished by the absence of previous history or 
of symptoms or signs indicating disease of the gall-ducts. If jaundice 
is present, it is not so intense as in tumors of the gall-bladder. While 
the gall-bladder is movable, it is not so distinctly so as movable kidney. 
The gall-bladder moves in an arc of a circle, the centre of which is at 
the edge of the right lobe of the liver. It can be pushed further to 
the left than to the right, but never downward as a movable kidney. 
Moreover, the gall-bladder is always palpable, the movable kidney 
cannot always be felt. The gall-bladder, if it contain calculi, is very 
hard compared to the kidney. Anuria does not occur. 

The kidney tends to spring back to its place in the loin ; the gall- 
bladder to the anterior part of the abdomen. Even if the gall-bladder 
is enlarged, the kidney can be felt by bimanual palpation ; while the 
opposite does not obtain. In cancer of the pylorus the emaciation and 
anaemia are more pronounced than in movable kidney. The vomit- 
ing, usually characteristic in that affection, and the physical signs of 
dilated stomach, can be made out. Tumors of the pelvic organs are 
determined by examination according to the usual methods. 

Horseshoe Kidxey. There are usually no symptoms. The kid- 
ney can sometimes be felt through the abdomen if its walls are relaxed, 
or by bimanual examination. 



910 SPECIAL DIAGNOSIS. 



Enlargement. Renal Tumor. 

Enlargements of the kidney may be detected by percussion ; the width 
of the kidney is increased, and the percussion-dulness therefore extends 
further to the right or left, according as the right or left kidney is 
affected. As the causes which produce enlargements of the kidney 
sufficiently great to be detected by percussion do not, with rare excep- 
tions, involve both kidneys at the same time, comparison of the two 
sides is of great value in the diagnosis. 

Renal tumors rarely bulge in the lumbar region, although there is 
a sensation of increased resistance in this area. The mass is never 
notched, is usually smooth, and often takes the shape of the kidney if 
that organ is involved in its entirety. Otherwise the outline is not 
reniform. The bowel is usually in front of the mass, although in 
tumors of the right kidney the csecum and colon may be pushed to the 
inner side, and of the left kidney the colon may be pressed outward. 

The diseases of the kidney attended by enlargement are : malignant 
tumors, cystic kidney, hydronephrosis and pyonephrosis, abscess, and peri- 
nephritic abscess. 

Sarcoma and Carcinoma of the Kidney. 

Either disease may be primary or secondary. Sarcoma may be con- 
genital. The tumor may occur at any age, but is relatively common 
in young children. Twenty-five out of sixty-seven cases collected by 
Dr. William Roberts occurred in children under ten years of age. In 
older persons it is often preceded by calculus. Symptoms: In some 
instances there are no symptoms during life. In others the disease 
may advance considerably before it presents any signs. If symptoms 
are complained of they are usually limited to pain, the occurrence of 
hematuria, or the development of a tumor. The pain is dull and seated 
in the lumbar region. It may be neuralgic in character; and, indeed, 
there may be a true sciatica with paresis of the leg from pressure of the 
tumor. The tumor (Plate XLV., Fig. 2) is firm ; its surface is smooth 
or nodulated. It may be felt in the loins, and in front, above the um- 
bilicus, a few inches to the right or left of the median line ; the descend- 
ing colon lies in front of the tumor. The latter may grow with great 
rapidity and attain enormous size, filling the abdominal cavity and giving 
rise to pressure-symptoms in surrounding organs. The growth occurs 
more often anteriorly and downward toward the pubis, because there is 
less resistance in these directions. As rapidly growing cancers are soft, 
the tumor frequently exhibits a certain degree of elasticity, which may 
be mistaken for fluctuation. It is immovable either by the hands or 
with respiration. 

On percussion the resistance is increased and the note is dull, except 
in front, where the colon, which has been pushed forward, gives a tym- 
panitic note. If the colon should be flattened out between the tumor 
and the abdominal wall, it may be felt as a band stretching across the 
tumor, with dullness on percussion. In such a case inflation of the 
colon will be of great assistance in the diagnosis. Rare physical signs 



DISEASES OF THE KIDNEYS. 911 

are pulsation and a blowing murmur. The hcematuria may be con- 
stant or intermittent. The clots of blood may cause renal colic. 

The general symptoms are those of carcinoma. A marked rapidity 
of the pulse has been noted in several cases. In girls a premature 
development of hair on the pubes and in the axilla? and pigmentation 
of the skin have been observed. 

Hemorrhage is an early symptom, and in the absence of nephritis or 
cystitis should always suggest tumor. It may occur early and may 
be intermittent or persistent. In some instances it occurs but once, 
usually it is frequent. When excessive, the growth is never innocent. 
Pain is not of much value, and may be absent until perinephritis occurs. 
Symptomatic varicocele may occur. The examination of the urine, save 
that it discloses the presence of blood, is negative. In this sense it is of 
value. Pus occurs if there is secondary infection or if calculi precede 
the growth. Rarely fragments of carcinoma are said to be detected. 
In order to determine the kidney affected separate urine should be 
obtained from each organ. 

The tumor must be distinguished from tumors of the lymphatic 
glands, of the liver, of the spleen, and of the ovary. It must not be 
confounded with psoas abscesses and perinephritic abscesses, which 
cause a tumor in the lumbar region. 

Cystic Kidneys. 

1. Congenital. The kidney consists of a small mass of cysts filled 
with clear fluid. It may interfere with the birth of the child on account 
of its large size. 

2. Acquired. The cause is trauma and obstruction of the ureter, the 
presence of which is determined by catheterization. The symptoms 
are those of a fluctuating renal tumor. The urine may be normal or 
hcematuria may be present. 

Hydronephrosis. 

Causes. It may be congenital. Obstruction of ureter by stone ; 
pressure of tumor ; twist, as in movable kidney ; exudates. 

Symptoms. In addition to the symptoms of the causal condition we 
have, upon the development of hydronephrosis, the presence of a tumor, 
arising in the region of the kidney and extending toward the middle 
line. Sometimes fluctuation can be detected ; often it cannot. Varia- 
tions in size of the tumor may occur with changes in amount of urine 
passed. Puncture, and the finding of a fluid with elements of urine in 
it, are valuable means of diagnosis ; but if the hydronephrosis is old, 
this fails, as the fluid loses its urinary character, and cannot, for instance, 
be distinguished from that of an ovarian cyst. When on one side the 
urine may be normal ; when on both sides it is diminished ; anuria and 
uraemia may occur. If pyelitis is present, pyuria is observed. 

Intermittent hydronephrosis is associated with movable kidney, hence 
it is more frequent in women. It is characterized by the development 
of a renal tumor with variable frequency, and with pain, nausea, and 
vomiting. At the same time the urine is scanty. In a few hours or 



912 SPECIAL DIAGNOSIS. 

days there is an increase in the amount of urine with subsidence of the 
tumor. 

Pain may or may not be present. Gastric symptoms are very com- 
mon. Either constipation or diarrhoea is seen. Hypertrophy of the 
left ventricle may occur, as in chronic nephritis. 

Hydronephrosis consists in a dilatation of the kidney pelvis with 
urine, which is prevented from escaping by obstruction of the ureter, 
either by the pressure of a tumor, or by disease of the bladder or ureter 
itself. In time the kidney atrophies from the pressure and a large cyst 
forms. The tumor has the physical characteristics of pyonephrosis, but 
the history is different, and if there is any discharge, it is free from 
pus. As in pyonephrosis, the tumor may become small, following a 
copious discharge — in this case of urine — or may even wholly disap- 
pear, if the obstruction is removed. This sign is pathognomonic. 

If obstruction continue to be absolute, the diagnosis must be made 
by the detection of a fluctuating renal tumor, the absence of fever and 
signs of suppuration, and by the result of exploratory puncture. The 
urine is usually free from pathological changes. 

It may be confounded with ascites, if very large, but hydronephrosis 
is rarely bilateral, and the fluid in it does not change its level upon 
change of position of the patient, as is the case with ascites. The 
history of the two conditions will be different. 

An ovarian cyst can usually be traced into the pelvis ; it does not 
carry the colon in front of it, and hence is dull, even on superficial 
percussion, and it leaves the loins resonant. 

Pyelitis. Pyonephrosis. 

Pyelitis is rarely primary ; usually secondary. Severe infectious dis- 
eases (typhus, variola, diphtheria, pyaemia) ; toxic substances ingested 
(cantharides, etc.) ; chronic nephritis ; inflammation of the bladder or 
ureter ; strictures of the ureter or urethra ; hypertrophy of the pros- 
tate ; spinal palsies of the bladder ; calculus ; parasites ; blood-clots, 
are the antecedent causal factors ; infection the active cause. 

Symptoms. The Urine. Pus in the urine with pelvic epithelium — 
although it is not safe to base a diagnosis on the presence of the latter ; 
casts of the canals opening into the pelvis are more characteristic ; 
epithelial casts, and casts containing micro-organisms. The urine is 
often increased, acid, and contains pus and albumin, rarely blood. 
Pyuria may be the only renal sign. In all forms of pyuria above the 
bladder Kelly withdraws the pus by catheterization and suction. He 
allows the catheters to remain from ten minutes to four or five hours, 
in order to estimate,the functional power of each kidney. Of course, 
the pus is studied microscopically and bacteriologically. Pain in the 
region of the kidney, often severe, is complained of, although it may 
be absent. When present, it is often of a tearing character. Tumor. 
A tumor is often present. It is most prominent in the loin or in the 
abdomen. In the latter the mass can be felt two inches to either side of 
the umbilicus, usually above the transverse line. 

Pyelitis differs from abscess of the kidney. The latter may be the 



DISEASES OF THE KIDNEYS. 913 

result of a local infection from the pelvis of the kidney or may be 
pysernic. 

In abscess of the kidney there is some fulness in the loin of the 
affected side. The kidney is felt to be enlarged, and is tender and 
painful. A tumor may be detected anteriorly. The diagnosis is based 
on a study of the cause (acute nephritis, pyaemia, impacted calculus 
in the ureter, erysipelas), or the detection of blood and pus in 
the urine, which is scanty, and on the constitutional symptoms. The 
progress of the case is usually acute. If the abscess is tubercular, 
tubercle bacilli can be detected in the purulent sediment of the urine, 
and there will be other foci of tuberculosis Avith a corresponding clini- 
cal history. 

When the pus is confined by an occluded ureter, the pelvis is over- 
distended. In pyonephrosis the tumor is tense, smooth, and globular. 
Fluctuation may be detected. Tenderness is usually absent ; the course 
is slow and does not affect the general health so much as abscess. The 
pus may be discharged copiously from time to time, and the tumor be 
therefore diminished in size. The urine may be occasionally almost 
clear. Pyonephrosis arises secondarily to pyelitis, and often after the 
latter has lasted some time. 

Fever is irregular, remitting, or septic. The fever and pyuria may 
be the only symptoms. If the bladder is healthy, its symptoms fail to 



aid in diagnosis. 



Perinephritic Abscess. 



It occurs as a primary disease in apparently healthy individuals, or 
after infectious diseases. 

Perinephritis arises usually from extension of inflammation and sup- 
puration from the kidney, but may be the result of strain, exposure to 
cold, or injury. Perinephritis may also be pysemic, and occur after 
infectious fevers, and in actinomycosis. 

Symptoms. The secondary forms have symptoms of the primary 
disease, and, later, swelling and pain in the renal region. 

Primary form. Chills and fever, pain, difficulty in defecation. The 
general condition suffers. Finally, in all cases, there is the formation 
of a swelling in the lumbar region, at first hard ; then oedema of the 
skin follows, and fluctuation is detected. The abscess may descend 
and point above Poupart's ligament. It may press upward and cause 
dyspnoea. Great tenderness and pain in the region of the swelling may 
arise, and the pain may radiate to the leg. Irregular septic fever and 
chills appear. The urine is not generally changed unless some com- 
munication with the pelvis or ureter has formed. The patient lies on 
his back, turned toward the affected side. The knee and hip of this 
side are flexed and the thigh rotated outward. The affection may simu- 
late coxitis and appendicitis. 

The swelling of a perinephritic abscess appears in the lumbar region 
of the side affected. It is rounded in form and doughy (Da Costa). 
Like other kidney tumors, it is not affected by respiration. The usual 
signs of confined suppuration exist, and pulmonary or pleural compli- 
cations may occur. As the abscess progresses, the local signs of suppu- 

58 



914 SPECIAL DIAGNOSIS. 

ration become more marked, the skin reddens, and pus may be discharged 
externally. 

The most marked subjective symptom is pain, which may amount 
to agony, and is paroxysmal ; soreness from restricted motion of the 
psoas muscle is apt to be complained of. 

A tumor was present in the loins in sixty-five out of seventy-one 
cases analyzed by Fenwick, but did not generally manifest itself until 
the inflammation had made considerable progress. There is dulness on 
percussion even in the early stage, and, later, fluctuation. The general 
symptoms are vomiting, constipation, fever, and sometimes rigors. It 
is more common in males than in females (sixty-one males to thirty- 
nine females in Fenwick' s cases). 

Hydatid Cyst. 

A hydatid cyst of the kidney presents the usual physical signs of such 
cysts. A fremitus may be detected, or small cysts may be found in the 
urine. 

It is comparatively rare. Usually there are no symptoms until a 
tumor is felt. Then pain gradually develops. The cyst may open into 
the pelvis of the kidney, and cysts or scolices be discharged, with colic. 

Pyelitis and cystitis may also develop. 

Echinococcus cyst may inflame and lead to general pysemia. Punc- 
ture of the discovered tumor is otherwise the only means of diagnosis. 
It must be differentiated from hydronephrosis and ovarian tumors. 
Puncture is necessary. 

Examination of the Urine. 

1. Inspection. The urine in health is a clear yellow or amber- 
colored fluid, having a specific gravity of about 1020, and generally acid 
in reaction. It contains normally about forty-five parts in the thousand 
of solid matter, the principal part of which is urea — twenty-one and a 
half parts. The other solids are uric acid and its salts ; certain extrac- 
tives — creatin, creatinin, ammonia, hippuric acid, xanthin, hypoxanthin. 
sarcin, pigment, etc. ; and chlorides, phosphates, sulphates, with their 
bases, soda, potash, lime, and magnesia. 

The volume of urine passed in twenty-four hours is usually from forty 
to fifty ounces, but it may fall to thirty ounces or rise to seventy with- 
out the existence of disease. Women are believed to pass from five to 
ten ounces less than men. The volume is diminished when the skin 
is acting freely, as in warm weather, and when the bowels are loose ; 
and, on the other hand, cold, constipation, and nervous excitement, espe- 
cially if it induce anxiety and fear, all tend to increase the quantity 
secreted. 

Color. The color of the urine is due largely but not wholly to 
urobilin, which is formed from the hsematin of the blood. The color 
deepens when the urine is concentrated, which occurs after a hearty 
meal, or exercise, especially in warm weather ; and it becomes paler 
when a large quantity is passed. The color is frequently changed in 



DISEASES OF THE KIDNEYS. 915 

disease. In fevers the urine, soon after being passed, is apt to become 
turbid from the precipitation of urates, and the color varies from white, 
especially in children, to yellow, brown, or pink. When the precipi- 
tate settles the supernatant urine may be high-colored and clear, or 
slightly opaque from some suspended matter. 

The admixture of pus and chyle gives the urine a milky color. The 
urine may also be yellowish-white and turbid from phosphates, semen, 
sarcinae, and bacteria. 

The urine is red, reddish-brown, or " smoky " in acute nephritis, the 
color being due to blood. It is bloody in haematuria, cancer of the 
kidneys and bladder, and in injuries of the genito-urinary apparatus. 
The urine is very red and clear when concentrated and containing a 
large amount of urates. The red color of the urine may be due to 
haemoglobin, constituting hemoglobinuria, or to excess of urobilin, as 
in scurvy and pernicious anaemia. Haemoglobinuria occurs as the result 
of the action of certain poisons, such as chlorate of potash ; in infectious 
diseases, such as scarlet fever ; and in malarial fevers ; also in a pecu- 
liar disease known as paroxysmal haemoglobinuria. 

Again, a golden-red discoloration of the urine is common in jaundice ; 
frequently the upper layers have a greenish tinge by reflected light. 

Finally, a red color is produced by the internal administration of 
logwood and fuchsin. 

A yellow color, when opaque, may be due to suspended phosphates 
and urates. Urine is sometimes golden yellow or of a saffron color in 
jaundice, and from the effects of santonin, picric acid, and rhubarb 
taken internally. A yellow or yellowish-white turbidity may be due 
also to a mixture of pus and phosphates, and sometimes to semen, sar- 
cinae, and bacteria. The urine usually becomes more or less opaque 
and yellow when it has undergone alkaline fermentation. Such a 
change occurs normally within a longer or shorter time after the urine 
has been passed. It is promoted by heat and exposure to air, and 
retarded by cold and exclusion from air. If possible, the urine should 
be examined before this fermentation has occurred. Pathologically, in 
cases of cystitis, the urine when passed is already in alkaline fermen- 
tation. 

The urine is sometimes chocolate-brown when it contains blood and 
the blood has been acted upon by the urine, producing methaemoglobin. 

Brown, greenish-brown, or black urine may result from contained bile- 
salts ; from indican ; from carbolic acid, creosote, and tar used inter- 
nally and externally ; from the internal use of senna, and in . cases 
where there are melanotic tumors. Senator injected melanin into 
human beings and obtained in four cases only a large indicanuria. 

Urine is pale usually in proportion as it is copious in quantity. It 
is paler in those who are using milk or vegetable diet than in those 
who eat meats. Under the influence of nervous excitement, especially 
anxiety and the dread of an approaching ordeal, such as an examina- 
tion, an abnormal quantity of very pale urine is secreted. 

Pathologically, pale urine is characteristic of diabetes, chronic Bright's 
disease, and polyuria. Such urine is also secreted in hysterical attacks, 
at the crises of febrile diseases, and in anaemic conditions. 



916 SPECIAL DIAGNOSIS. 

The Quantity. The volume may be increased, diminished, or 
unchanged in disease. It is increased principally in three diseases — 
diabetes mellitus, diabetes insipidus, and in the middle period of chronic 
Bright' s disease, especially the interstitial form. In diabetes mellitus 
it sometimes exceeds thirty-two pints. It may be increased also in 
hypertrophy of the left ventricle, which induces greater pressure in the 
renal arteries as well as in the whole arterial system ; and also in cystic 
degeneration, and in double hydronephrosis. 

Diabetes Insipidus. This form of diabetes differs from the sacchar- 
ine in that the urine is normal, but of low specific gravity. The 
disease may come on suddenly after mental emotion, or develop grad- 
ually. The amount of urine may range from ten to forty pints. The 
urine is of low specific gravity — from 1001 to 1005. It is pale and 
watery. The solid constituents are not reduced. Urea is sometimes 
increased, but abnormal constituents are very rare. The passage of 
large amounts of urine induces thirst, but otherwise the symptoms do 
not tally with the symptoms of diabetes mellitus. The patients are 
usually well nourished. 

The disease is usually secondary to some organic disease of the brain, 
or of the abdomen, as tubercular peritonitis, abdominal tumors, or 
aneurisms. It usually occurs in males, and is often hereditary. It is 
most common in young people. Traumatism, meningitis, affections of 
the brain involving the sixth nerve, tumors of the brain or of the 
medulla, are causal factors. It may follow fright, a protracted debauch, 
or perturbation of the nervous system from other causes. 

The diagnosis is not difficult. It must be distinguished from the 
polyuria that is seen in chronic interstitial nephritis, and in amyloid 
disease. In hysteria, polyuria is common, although transitory. The 
presence of the stigmata and other hysterical manifestations lead to the 
diagnosis in hysteria. 

The urine is diminished in acute nephritis and in the final stages of 
chronic nephritis ; sometimes, also, it is diminished in the middle 
period of chronic nephritis, but usually it is here increased. All dis- 
eases which directly or indirectly impair the force of the circulation 
lessen the secretion of the urine. Hence, the quantity is diminished in 
diseases of the heart-muscle and in valvular diseases not fully com- 
pensated ; in emphysema and in chronic bronchitis. It is lessened also 
in cirrhosis of the liver. In febrile diseases the urine is scanty and 
high-colored, and sometimes it is almost suppressed (anuria). 

The urine is sometimes suppressed in acute nephritis, such as follows 
scarlet fever, and in the final stages of all the organic affections of the 
kidneys —chronic nephritis, hydronephrosis and pyonephrosis, etc. It 
may result (1) from the destruction of the secreting tissue of the kidney 
or interference with its nervous or vascular supply, or (2) from mechan- 
ical obstruction to the outflow of urine. To the first class belong the 
cases of suppression occurring in acnte and chronic nephritis, and the 
suppression from shock and collapse, whether occurring in the stage of 
collapse of yellow fever, cholera, and other grave febrile diseases, or 
from serious internal injuries. 

Such suppression sometimes follows slight operations on the urethra 



DISEASES OF THE KIDNEYS. 917 

(urethral fever) ; or results from the internal administration of drugs 
the excretion of which occasions violent irritation of the kidney — 
cantharides, turpentine, and even the inhalation of ether. Clinically, 
suppression not due to obstruction is distinguished from the obstructive 
form by the character of the urine, which is usually not entirely sup- 
pressed, and by the more rapid course of the disease. The urine, 
according to Roberts, is either concentrated or it contains albumin, 
blood, and casts. Death or recovery results within a day or two. In 
the obstructive form, on the other hand, the urine which escapes past 
the obstacle is pale, watery, and devoid of albumin and casts. 

Obstructive suppression is the result of the plugging of the ureter by 
a calculus, when the opposite kidney is either absent or incapable of 
secreting. It also results from the occlusion of the ureters by morbid 
growths, especially at the vesical orifices, from lateral pressure upon 
the ureters, or from some interference with or malformation of the 
ureters or renal arteries. 

Acute transient obstructive suppression occurs sometimes in persons 
with enlarged prostates, or old strictures, who have drunk too freely of 
alcoholic beverages, and, perhaps, have wound up a debauch by sexual 
intercourse. 

The Density of the Ukine. The average density of normal 
urine is about 1020. It may fall to 1015 or rise to 1025, depending 
upon the quantity of fluid and food taken, the condition of the atmos- 
phere, especially as regards temperature, and upon mental influences 
usually of an emotional character. The specific gravity of the urine 
is tested by a urinometer graduated for degrees of density between 
1000 and 1040. Only a reliable instrument should be used. As the 
density of the urine passed at different times during the day varies 
greatly, the urine for the whole twenty-four hours should be saved 
and a specimen of this tested. 

The method of taking the specific gravity is very simple. A test- 
tube or graduate, having a diameter of about one and a quarter inch 
and a length of six or seven inches, is filled with urine to such a point 
that the lowest part of the urinometer when inserted floats clear of the 
bottom of the tube. The instrument must also float free of the sides 
of the tube. The specific gravity should then be read off from below — 
that is to say, by holding the tube up so that the level of the fluid is a 
little above that of the eye. Most urinometers are graduated for 60°, 
but in ordinary examinations it is not necessary to have the urine ex- 
actly at this temperature ; it should, however, be allowed to cool after it 
has been passed, otherwise the specific gravity will appear to be too low. 

In disease the specific gravity varies more widely than in health ; it 
may fall to 1000 or 1005 in diabetes insipidus and chronic Bright' s 
disease, and rise to 1060 or even higher in diabetes mellitus. As a 
rule, to which the urine in diabetes mellitus is the principal exception, 
the color is an index of the density, pale urine being of low density 
and high-colored urine of high density. 

The density is increased when the urine is scanty in amount, whether 
as the result of fever, acute nephritis, large consumption of solid food, 
exercise, or free sweating. In all such cases the specific gravity rarely 



918 SPECIAL DIAGNOSIS. 

rises above 1035, and usually not above 1028 or 1030. AVhen the 
specific gravity rises above 1035, and the urine is pale in color, the 
presence of sugar is to be suspected ; and when it rises above 1040 
sugar is almost certainly present. 

The specific gravity is lowered by drinking copiously, by the effect 
of external cold, by a diet of vegetables and milk, and, in general, by 
the same causes that make the urine copious. Usually, but not always, 
a urine containing a large amount of albumin is of low density. 

Pathologically, a low specific gravity is encountered in diabetes in- 
sipidus, in which it may fall nearly or quite to 1000 ; generally in the 
middle or quiescent period of chronic Bright' s disease ; in the crisis of 
fevers ; in obstructive suppression ; in hysterical attacks, and in hydro- 
nephrosis. 

Specific Gravity as an Index of the Amount of Solids. If the last two 
figures of the specific gravity be doubled, the sum will represent the 
amount of solid matter in 1000 grains of urine. This is Trapp's 
method ; the estimate is only rough, but it is useful. Of course, the 
urine for twenty-four hours must be used. 

The Re action . The reaction of healthy urine is usually acid, but 
it may be neutral or slightly alkaline about two hours after a meal of 
mixed food. The acidity is tested with litmus-paper ; the blue paper 
is turned purple or red by an acid, and the red paper is turned blue by 
an alkali. Violet paper is to be preferred, as it is suitable for showing 
both reactions, an alkali turning it blue and an acid red. 

The acidity of the urine is increased in gout, lithiasis, acute rheuma- 
tism, diabetes, chronic Bright/ s disease, and as the result of the admin- 
istration of vegetable or mineral acids. 

The urine is all: aline as the result of alkaline fermentation in the 
bladder in cystitis ; from the presence of much blood or pus ; from 
prolonged immersion of the body in a cold bath ; in debilitating dis- 
eases and in some cases of nervous dyspepsia, and as the result of the 
internal administration of alkalies. 

Urinary Sediments. A white, flocculent sediment, composed of 
epithelium and mucus, occurs normally in most urines after they have 
stood for some hours. 

A dense sediment, varying in color from that of brown sugar to pink 
or red, consists of amorphous urates. It dissolves upon the appli- 
cation of heat. A sediment usually resembling red pepper, but some- 
times of a brown color, consists of uric acid. It can be proved to be 
uric acid by the murexid test. The suspected material is placed in a 
crucible or evaporating dish with a few drops of nitric acid. As heat is 
applied the uric acid or amorphous urate dissolves with effervescence. 
Heat is now kept up until the material is evaporated to dryness ; it is 
then allowed to cool. If it is now touched with a glass rod, dipped in 
strong ammonia, a characteristic blue or violet color is produced. Uric 
acid is not usually so abundant as the sediment of amorphous urates ; 
it sinks more rapidly, and is deposited from acid, high-colored urines. 

A yellowish or whitish sediment may consist of urate of sodium. 

A white sediment usually consists of phosphates, associated with 
which we sometimes fi nd a white sediment consisting of urate of ammo-. 



DISEASES OF THE KIDNEYS. 919 

nium, with or without pus. Such urines are alkaline. A white sedi- 
ment may be due to uric acid, especially in children. 

A yellowish-white sediment may consist of pus, with or without 
mucus. If the urine is acid, the sediment is loose and free to move ; 
but when the urine is alkaline the sediment consists of a viscid, coherent 
mass, which can be drawn out into tough, stringy filaments. 

A chocolate-brown sediment, occurring in a reddish, smoky urine, 
consists of blood from the kidneys. Clots of blood come from the 
ureters, bladder, or urethra. 

Odor. The odor of normal urine is sometimes spoken of as aromatic, 
but generally it is sufficiently characteristic to be best described as 
urinous. When the urine is concentrated the odor is intensified, and 
may become unpleasantly strong, like the urine of the horse. 

Certain articles of food, such as garlic and asparagus, give the urine 
characteristic odors. Turpentine, both when taken internally and in- 
haled, gives to it the odor of violets. The odors of copaiba and of cubebs 
can easily be detected in the urine of patients who are taking these drugs. 

In marked cystitis the natural urinous odor becomes more pungent, 
and is blended with a strong ammoniacal odor. When much pus is 
present, and the urine has stood awhile, a putrid odor is developed. 

In diabetes mellitus the urine has a sweetish, hay-like odor. In 
diabetic coma the odor is sometimes that of chloroform, due to the 
presence of acetone and diacetic acid in the urine. This odor, however, 
is more likely to be detected in the breath. 

2. Chemical Examination of the Urine. Examination of the urine 
by the unaided senses, which has been dwelt upon thus far, is simply 
preliminary to an examination by chemical methods and by instruments 
of precision, particularly the microscope. 

Urea. Urea is freely soluble in water, and hence never appears as 
a sediment. It is the most important final product of nitrogenous dis- 
integration in the body, and is an index of the eliminative power of the 
kidneys. Usually the density of the urine increases in proportion to 
the amount of urea contained in it. The average daily amount of urea 
excreted by an adult man between the ages of twenty and forty years 
is about 500 grains. The urea, like the total volume of the urine, is 
subject to variations within the limits of health. It is increased after a 
meal, especially if the latter be rich in nitrogenous food ; after copious 
ingestion of liquids, and by a close atmosphere. On the other hand, 
fasting, free perspiration, a loose condition of the bowels, and a vege- 
table or milk diet diminish the quantity of urea. Again, the quantity 
varies with the age of the person. According to Ralfe, at five years 
the amount daily is 180 grains ; at 12, 320 ; at 21, 535 ; and at 40 
years, 555 grains. 

A large man will excrete absolutely more than a small man, and a 
large, muscular man will excrete relatively more than a fat man of the 
same height. 

The excretion of urea is increased in fever and inflammatory dis- 
eases ; in diabetes mellitus and insipidus ; in malaria, pernicious anseinia, 
and after a crisis in pneumonia. It is increased also by certain bever- 



920 SPECIAL DIAGNOSIS. 

ages, as coffee, and by many drugs, especially those which act as hepatic 
stimulants. 

It is diminished in all forms of nephritis, especially when uraemia 
results ; in acute gout and chronic rheumatism ; in disease accompanied 
by emaciation and cachexia ; and in leprosy, pemphigus, melancholia, 
imbecility, catalepsy, hysteria, and cholera (Saundby). 

Estimation of Urea. For the methods employed in the exact quan- 
titative estimation of urea the student is referred to special works on 
the urine. 

For ordinary clinical purposes the apparatus devised by Professor 
Charles Doremus, and known as his ureometer, gives sufficiently accu- 
rate results. The principle upon which it is based is that urea when 
brought in contact with sodium hypobromite is decomposed, and free 
nitrogen is eliminated. The nitrogen evolved is the measure of the urea 
contained in the urine. The instruments are graduated so that each 
division of the scale represents one grain of urea per fluidounce of urine. 

The hypobromite solution is prepared by dissolving 100 grammes of 
sodium hydroxide in 250 c.c. of water, cooling the solution, and then 
adding 25 c.c. of bromine. 

It is better, however, to freshly prepare the hypobromite solution 
for each examination. This can readily be done by having a solution 
of sodium hydroxide containing six ounces to a pint of water. It 
should be kept tightly corked with a rubber or paraffined stopper. 
The sodium hydroxide solution is poured into the long tube of the 
ureometer to the mark =, then one-tenth of its volume of bromine is 
introduced by means of a pipette, and sufficient water added to fill the 
long arm and the bend of the tube. The hypobromite solution should 
fill the tube completely, and any bubbles rising to the top of the tube 
should be removed before the introduction of the urine. The pipette 
is then filled with the urine up to the 1 c.c. mark, any urine adhering 
to its surface being carefully wiped off. The pipette is introduced care- 
fully, so as not to compress the bulb until the point extends as high up 
as possible beyond the bend. The bulb is now compressed slowly until 
1 c.c. of urine has been introduced. Decomposition of the urea occurs 
and bubbles of nitrogen rise to the surface of the long arm of the tube ; 
when bubbles of gas cease to be evolved the volume of nitrogen gas is 
read off, and according to the graduations on the tube considered as so 
many grains of urea per fluidounce of urine, or as so many milligrammes 
of urea in 1 c.c. of urine, according to whether it is graduated in the 
English or the metric system. 

The Chlorides. The presence or absence of chlorides is sometimes 
of diagnostic value. They are increased when absorption of exudations 
or transudations is going on, and in malarial fevers, diabetes insipidus, 
and Bright's disease. They are diminished or absent in pneumonia 
during its progressive stage, and in fevers. The chlorine of the chlo- 
rides can be detected and roughly estimated by an 8 or 10 per cent, 
solution of argentic nitrate. A few drops of nitric acid are first added 
to the urine, to prevent the silver from precipitating phosphoric acid. 
A single drop of the silver solution mentioned will precipitate the 
chlorine of the chlorides in a thick white lump, which falls to the bot- 



DISEASES OF THE KIDNEYS. 921 

torn of the test-tube, provided the amount present is normal. If, on 
the other hand, the quantity is diminished to one-tenth per cent, or 
less, it will not be precipitated in a lump or lumps, but a white cloudi- 
ness is produced which renders the whole solution opaque. If no pre- 
cipitation or cloudiness occurs, the chlorides are absent. 

Serum-albumin. Albumin is of common occurrence, but cannot 
ever be looked upon as a normal constituent of the urine, though its 
presence by no means indicates disease of the kidneys. The ordinary 
form is serum-albumin, but other proteids, as globulin, mucin, pep- 
tone, albumose, fibrin, and also haemoglobin methsemoglobin, are found 
at times. The most trustworthy tests for ordinary albumin (serum- 
albumin) are : boiling, with the addition of nitric or acetic acid ; over- 
laying cold nitric acid with urine (Heller's test) ; the picric acid, the 
potassium ferrocyanide, and the potassium-mercuric-iodide (Tanret's) 
tests. The author believes that many of the recent tests, such as sodium 
tungstate, acidulated brine, magnesium nitrate, phenic-acetic acid, and 
trichlor-acetic acid, are too sensitive and precipitate other substances 
in the urine, and, therefore, are not reliable for clinical work. 

Serum globulin responds to all the following tests for serum-albumin. 
Its differentiation is not difficult, but usually unnecessary. (See note 
on page 937.) 

Boiling and Nitric Acid Test. A narrow, long test-tube is filled two- 
thirds full of urine and the upper third boiled thoroughly, and then a 
few drops of nitric acid are added. Any albumin present will be coag- 
ulated and appear as a white cloud, contrasting strongly with the clear 
unboiled urine beneath it. When the albumin is moderate or even 
small in amount it can be detected without difficulty by simply holding 
the test-tube up to the light. When there is only a faint trace present 
it will be overlooked unless the tube be examined against a dark sur- 
face in such a way that the light falls upon it from above, in front, 
and preferably a little to one side. A cloud may escape detection when 
looked for by artificial light, but may be distinct by daylight. Serum- 
globulin is also precipitated by this test. But serum-globulin is not 
often present by itself, and its significance is not yet understood. It 
may be detected in any urine, as Roberts points out, by diluting the 
urine with pure water, the urine then becoming more or less milky. 
It may be removed from urine by saturating the latter with magnesium 
sulphate and filtering off the precipitated globulin. The presence of 
serum-globulin in no way interferes with the test for serum -albumin. 

If the urine is opaque from amorphous urates, it is unnecessary to 
filter them out ; heat much below boiling will dissolve them, the pre- 
cipitation of albumin occurring later at a higher temperature. 

If the urine is alkaline or faintly acid, phosphates will produce a 
cloud upon heating the urine ; but they are instantly dissolved upon 
the addition of a few drops of nitric or acetic acid. 

Mucin produces an opalescence upon heating with an organic acid, 
but Saundby declares that it coagulates not in flocculi, as is the case 
with albumin, but in the form of tiny filaments. 

Boiling and Acetic Acid Test. This is preferred by many to the 
preceding test. It is performed in a similar manner. Acetic acid is, 



922 SPECIAL DIAGNOSIS. 

however, not reliable for acidulation : it precipitates the mucin which 
is often found in healthy urine, forming a white cloud which is apt 
to be mistaken for albumin ; this is especially true in urines of high 
specific gravity containing uric acid, urates, or oxalates. 

The Nitric Acid (Heller's) Test This test, while not so delicate as 
the acetic acid test, is very simple and accurate in its results. Cold 
nitric acid is poured into a test-tube to the depth of about an inch. 
The tube is then inclined to an angle of about 45 degrees, and urine 
allowed to flow gently down upon the acid by trickling along the side 
of the tube from a pipette or glass tube. At the point of contact of 
the acid and urine a zone of white, coagulated albumin forms. The 
test can also be made as follows : Into a short, broad test-tube several 
cubic centimetres of urine are poured ; nitric acid is introduced with 
a pipette provided with a rubber bulb by passing the pipette through 
the urine to the bottom of the tube and gently pressing the rubber 
bulb ; care must be taken to withdraw the pipette as the last portion 
of acid is expelled, so that no air-bubbles will break up the point of 
contact of the urine and acid. The thickness of the white zone is 
generally an index of the amount of albumin present. If there is 
barely a trace of albumin, half an hour may be required to develop 
any opalescence. 

A cloud of urates is sometimes produced and obscures the test. This 
cloud does not, however, begin at the point of contact and extend 
upward, but at the upper level of the urine and extends downward, 
and is dissipated by heat. 

Patients who are taking copaiba or cubebs pass a urine which gives 
a white zone at the point of contact with cold nitric acid, but heat 
diminishes the opacity, and the precipitate is soluble in alcohol ; the 
odor of the drugs in the urine assists in the detection of their presence. 

The Picric Acid Test. This is an extremely delicate test for albumin. 
A saturated solution of picric acid is allowed to flow down upon and 
slightly mix with the upper layers of the urine, which half fills a good- 
sized test-tube. At the point of contact an opaque white zone of coagu- 
lated albumin is formed. If no white zone appears, albumin is almost 
certainly absent. Hence, the picric acid test is a valuable negative 
test. But, unfortunately, a white zone is formed by peptone, mucin, 
and various alkaloids, particularly quinine. The white zone produced 
by the presence of the substances just named disappears upon the appli- 
cation of heat, whereas an opalescence due to albumin becomes diffused 
throughout the whole urine. 

The Potassium Ferrocyanide Test. This test is highly recommended 
as simple, rapid, and accurate by Purdy, who performs it as follows : 
Into a test-tube are poured fifteen to thirty drops of acetic acid, and 
then two or three times that amount of potassium ferrocyanide solution 
(1 to 20) is added, and the two thoroughly mixed by shaking the tube. 
The urine is now added to the depth of two-thirds of the test-tube. If 
any albumin is present, it will be precipitated throughout the whole 
volume of urine in the form of a milk-like flocculent cloud, more or 
less according to the amount of albumin present. By this method all 
modifications of albumin, acid or alkaline, are precipitated and the 



DISEASES OF THE KIDNEYS. 923 

precipitation of mucin is avoided. It gives no reaction with phosphates, 
urates, peptones, vegetable alkaloids, or the acids found in the urine 
after the ingestion of copaiba, etc. This test may also be performed 
as follows : An ordinary test-tube is half filled with urine and a 
drachm or two of the potassium ferrocyanide solution (1 to 20) are 
added. After thoroughly mingling the reagent and the urine a few 
drops of acetic acid are added. If albumin is present, it will plainly 
come into view. This test, therefore, depends upon the production of 
a cloudiness or milkiness throughout the entire mixture in the tube. 
To some eyes the albumin is not so readily perceived as in those tests 
which depend upon the formation of a distinct line at the point of contact. 

The Potassium-mer curio Iodide Test (Tanrefs). The solution is made 
as follows : Potassium iodide, 3.32 grammes ; bichloride of mercury, 
1.35 grammes; acetic acid, 20 c.c. ; distilled water about 30 c.c. (the 
potassium iodide and the bichloride of mercury should be dissolved 
separately in the water and the solution mixed, to which the acetic acid 
is added and the whole made up to 60 c.c. with distilled water). As 
thus prepared the test is applied by the contact-method by overlaying 
the reagent with urine. This test responds to all modifications of albu- 
min, also to peptones and proteoses, as well as to the vegetable alkaloids 
and acids found in the urine after the ingestion of copaiba, etc. All 
reactions except those occurring with albumin, mucin, and the acids 
found in the urine after the ingestion of copaiba, etc., disappear with 
heat. It is a very good and delicate control-test for albumin. The 
solution, however, is of a yellowish hue, quite similar to the color of 
urines of low specific gravity. This sometimes renders the line of 
contact difficult to perceive. 

It is well to follow a routine method in testing for albumin : first, 
by boiling and the addition of nitric acid, and then the contact (Hel- 
ler's) test ; if there is doubt, either the potassium ferrocyanide or picric 
acid test ; finally, Tanret's solution will reveal minute quantities of 
albumin, and may be used as a confirmatory test. 

In all the tests for albumin mentioned a clear urine is necessary, 
especially when the amount of albumin is very small. This can be 
obtained by filtration when the opacity is due to pus, blood, mucus, 
and uric acid ; and, more effectively, by the addition of a small quan- 
tity of sodium hydroxide, warming slightly, and filtering. If the 
filtrate is not clear, a few drops of magnesium fluid (sulphate of mag- 
nesium, pure ammonium chloride, and pure liquor ammonise, of each 2 
drachms ; distilled water, 2 ounces), as recommended by Hoffmann and 
Ultzmann, may be added, and the urine again warmed and filtered. 

Resume of Tests for Albumin. 

1. The heat test. 

A. Method : Albumin is precipitated on boiling. 

B. Exception : 1. In alkaline urines albumin may be overlooked 
from the formation of soluble potassium and magnesium compounds. 
When patients are taking alkaline salts the test may be fallacious. 

2. An excess of acid may also interfere with the test. 

3. Feebly alkaline or neutral urines produce a precipitate of earthy 
phosphates, but it is instantly soluble in a small quantity of acid. 



924 SPECIAL DIAGNOSIS. 

4. Patients on a vegetable diet pass urine containing carbonates which 
precipitate with heat. The addition of an acid causes great evolution 
of gas. 

II. The heat and acetic acid test. 

Method : Determine the reaction of the urine. If alkaline, make 
faintly acid with acetic acid ; then boil and add a little more acetic 
acid. If there is no precipitate, boil again. The acetic acid precipitates 
nucleo-proteids, which are excluded by the methods above described. 

III. The heat and nitric acid test. 

A. Method : Bring the urine to the boiling-point and add nitric 
acid, drop by drop, shaking the mixture between each addition. A 
small precipitate is thrown down even if a very small amount of albu- 
min is present. The nitric acid should not exceed more than one-tenth 
of the volume of urine examined. The urine must not be heated after 
the addition of the acid. 

B. Exceptions : 1. In concentrated urines, uric acid or its salts 
may precipitate. Distinguish from albumin by filtering off the pre- 
cipitate and testing it by the biuret reaction, or dilute the urine with 
an equal volume of water when uric acid will not precipitate. 

2. Resin acids in turpentine, benzoin, cubebs, and other balsams, if 
present in the urine, are precipitated by nitric acid. Distinguish from 
albumin by adding one or two volumes of alcohol when the solution is 
cool. The precipitate of resin acids is dissolved. 

3. In urines containing biliverdin a precipitate is formed. Distin- 
guish from albumin by adding alcohol, which dissolves biliverdin. 

IV. Cold nitric acid test. 

A. Method : Pour the urine gently on the nitric acid. The albumin 
coagulates in the presence of an excess of strong nitric acid. A ring 
appears at the surface of contact if albumin is present. A second ring 
may be seen y 1 ^ to 1 cm. above the junction, due to nucleo-proteids. 
Distinguish from albumin by repeating the test with urine diluted 
with two or three volumes of water. The albumin rin^ diminishes 
and the nucleo-proteid ring is unchanged or increased. A haze due to 
nucleo-proteid may form, and also continue after dilution. 

B. Exceptions : 1. In concentrated urines a secondary ring due to 
uric acid may form above the junction. It is soluble on gently heating, 
and does not form when the urine has been diluted. 

2. In highly concentrated urine a precipitate of nitrate of urea may 
fall. Distinguish by its crystalline nature. 

3. Resin acids cause a precipitate of uniform cloudiness. Distinguish 
by solubility in alcohol. 

4. In highly colored urines the urinary pigments form a colored 
ring at the plane of contact, and in bilious urines the play of colors, 
as in Gmelin-Malin-Heintz's test for bile, is seen. 

5. The urine of patients taking alkaline iodides gives a dense brown 
ring of iodine. Distinguish by adding a few c.c. of chloroform and 
mixing them. A violet tinge is imparted to the liquid. 

6. Albumoses are precipitated, as well as all forms of albumin. Dis- 
tinguish by the previously mentioned tests. Peptone and vegetable 
alkaloids are not precipitated. 



DISEASES OE THE KIDNEYS. 925 

V. The potassium ferrocyanide and acetic acid test. 

A. Method : It is best performed as a ring test. The urine should 
be carefully run into a mixture of twenty or thirty drops of acetic acid 
and sixty or ninety drops of saturated solution of potassium ferrocyanide. 
A white ring forms at the junction if albumin is present. With small 
amounts of albumin the ring takes some minutes to form. 

B. Exceptions : 1. Albumoses are precipitated. They are soluble 
in excess of acetic acid. They disappear on heating and reappear on 
cooling. 

2. Resin acids give a precipitate ivhich is soluble in alcohol. 

3. Phosphates, urates, alkaloids, and peptones are not precipitated. 

VI. Roberts' brine test. 

Saturated sodium hydrate solution with 5 per cent, hydrochloric acid. 
It does not darken the urine nor precipitate uric acid. 

A. Method : Use the ring test, which shows albumin and albumoses. 

B. Exceptions : Resin acids precipitate. Distinguish by dissolving 
in alcohol. 

VII. The salt and acetic acid test. 

The acetic acid is substituted for HC1, and a large excess of salt 
solution used. 

A. Method : The salt solution is first added to the urine and 
thoroughly mixed. Acetic acid is then poured in. Nucleo-proteids 
are not precipitated. (All other forms of albumin are precipitated.) 
Salt and vinegar may be used, and the mixture heated in a metal spoon. 

B. Exceptions : 1. Albumoses form and disappear on heating, to 
reappear on cooling. 

2. If albumoses and albumin appear together, boil for a short time 
and filter the hot fluid through a warm filter. The clear filtrate becomes 
turbid from albumoses as it cools. 

3. Resin acids and uric acid are precipitated, the latter only in con- 
centrated urines, and after standing. Distinguish by the usual tests. 

V. and VI. do not generally precipitate nucleo-proteids. With 
VII., if equal parts of urine and salt solution are used with a few 
drops of acetic acid, nucleo-proteids are not precipitated. The solution 
must be boiled when test VII. is employed. 

VIII. Salicylsulphonic acid. 

All forms of albumin are precipitated. The precipitate becomes 
flocculent on heating. If the urine is alkaline more of the reagent is 
needed than if acid. Phosphates, urates, bile, alkaloids, and drugs do 
not give a reaction. 

A. Method : After adding the solution to the urine heat and allow T 
to stand. 

B. Exceptions : Albumoses are precipitated, but disappear on heat- 
ing and reappear on cooling. 

IX. Trichloracetic acid. 

Exceptions : 1. Precipitates uric acid when in excess. Distinguish 
by heating, which dissolves the acid, or dilute the urine before applying 
the test. 

2. Nucleo-proteids give an opalescence. Albumoses are not pre- 
cipitated. 



926 



SPECIAL DIAGNOSIS. 



Fig. 205. 



X. Picric acid. 

A. Method : A saturated solution of picric acid must be used alone, 
in combination with HC1, or with acetic acid. Value doubtful. 

B. Exceptions : Uric acid, creatinin, nucleo-proteids, alkaloids, potas- 
sium salts, and albumoses are precipitated. 

XI. Millard's reagent. 

Value doubtful. Precipitates albumoses, nucleo-proteids, alkaloids, 
and resin acids. Distinguish by usual tests. 

XII. Tanret's reagent. 

Very delicate. Precipitates all forms of albumin, albumoses, nucleo- 
proteids, peptones, alkaloids, and resin acids. Distinguish by usual 
tests. 

XIII. Spiegler's reagent. 
Delicate. Precipitates albumin, albumoses, and nucleo- 
proteids, but not peptones. 

XIV. Acetic acid. 

Method : Filter the urine and add acetic acid to a 
portion, pouring the two in the tube held against a black 
background. Albumin and nucleo-proteids are precipi- 
tated. Distinguish by diluting the filtered urine with two 
or three volumes of distilled water, then add acetic acid, 
and compare the precipitate with that in an undiluted 
specimen. A nucleo-proteid precipitate will increase in 
intensity. An albumin precipitate will diminish or re- 
main unchanged. 

Salicylsulphonic acid is the most delicate test. An 
objection to it is the fact that it precipitates nucleo- 
proteids. Control the test by Heller's cold nitric acid 
test, from which the nucleo-proteids are removed, as 
above described. 

The quantitative estimation of albumin is of some im- 
portance. The most direct method is by coagulating the 
albumin by boiling, collecting it upon a weighed filter, 
washing with water and finally with alcohol, drying and 
weighing it. Such a process, however, consumes too much 
time for clinical purposes, and it is not faultless. An 
approximate estimation may be made by boiling the urine 
in a test-tube, adding several drops of nitric acid, allowing 
the albumin to settle, and then comparing the depth of 
albumin with the height of the column of urine. In this 
way we may speak of urine furnishing one-tenth or one- 
quarter of its bulk of coagulated albumin. 

Esbach has invented an albuminimeter (Fig. 205) which 
gives good results. The solution used to precipitate the 
albumin consists of 10 grammes of picric acid and 20 
grammes of citric acid, chemically pure and dry, dissolved 
in 900 c.c. of hot water ; and after cooling, diluting the 
solution to 1000 c.c. The urine is diluted with a definite 
amount of water if it contains too much albumin. The albuminimeter 
is filled to the mark U with urine, and from that mark to R with the 



rl 



Es bach's 
albuminimeter. 



DISEASES OF THE KIDNEYS. 927 

reagent. The tube is then corked with a rubber stopper, turned upside 
down ten times, so as to mix the urine intimately with the reagent, and 
then allowed to stand undisturbed for twenty-four hours. At the end 
of this time the depth of the sediment of coagulated albumin is ascer- 
tained by observing where the top of the sediment comes in contact 
with a mark on the scale on the tube. Each mark corresponds to one- 
tenth per cent, of albumin. 

This estimation, as already stated, is not absolutely accurate. Never- 
theless, if used systematically, and always in the same way, relative 
values will be obtained, and these are the most important in watching 
the progress of a case, as they give positive information regarding an 
increase or diminution of the amount of albumin in the urine. It 
scarcely need be said that the urine tested must be a portion of the 
whole twenty-four hours' urine. 

The estimation of the amount of albumin is also readily made with 
the centrifugal machine : to 10 c.c. of the albuminous urine are added 
3.5 c.c. of potassium ferrocyanide solution (1 to 10) and 1.5 c.c. of 
acetic acid ; the mixture is then revolved in the machine about three 
minutes, and the amount of precipitate read off. 

Albuminuria. Albuminuria is not indicative of disease of any one 
organ, nor does it point to any general pathological condition. It 
occurs as follows : 

1 . In diseases of the kidney : acute and chronic Bright' s disease, amy- 
loid disease, tuberculosis, cancer, abscess, and calculus. 

2. In disturbances of the circulation : diseases of the heart and chronic 
pulmonary diseases, as emphysema ; obstruction of the renal arteries or 
veins, cirrhosis of the liver, peritonitis, pregnancy, abdominal tumors ; 
in passive congestions due to great weakness ; in anaemia and Graves' 
disease. 

3. In febrile and inflammatory diseases : in the eruptive and infec- 
tious fevers, and in rheumatism, diphtheria, pneumonia, and gout. 

4. In blood diseases : purpura, leucocythsemia, and scurvy. 

5. From the poisonous action of drugs : lead, turpentine, and others. 

6. In nervous disorders : concussion of the brain and cerebral hemor- 
rhage, epilepsy, tetanus, and delirium tremens ; as Pye-Smith remarks, 
it is doubtful whether albuminuria is caused by the nervous diseases. 

7. Local extra-renal affections : pyelitis, cystitis, gonorrhoea, and 
leucorrhoea. 

8. Functional. In young persons, particularly of the male sex, there 
occurs occasionally slight albuminuria after exercise, a special diet, or 
a cold bath. Albumin may be found after rising in the morning, or 
early after dinner, or toward evening. On account of its occurring 
only at certain times it has been called " cyclical " or " intermittent," 
and because there is no evident disease present, it is occasionally spoken 
of as " physiological " albuminuria. 

Goodhart examined the urine of 1500 individuals and noted albumin 
in 272, or in 20 per cent. In 39 cases the albuminuria could not posi- 
tively be said to be due to disease of the kidney. Of these 39, 26 were 
males and 13 females. In 32 of the 39 cases it was temporary, and in 
most of them it had disappeared within forty-eight hours, or sooner. 



928 SPECIAL DIAGNOSIS. 

In 2 cases there were oxalates in the urine ; in 1 hsemoglobinuria ; in 8 
leucorrhoeal discharges and discharges from other parts of the genital 
passages (see division 7) ; and in 17 a markedly neurotic temperament. 
These last he thinks the most typical cases of intermittent albuminuria ; 
on the whole, he regards the condition as less common than has been 
supposed. 

One variety of functional albuminuria is apparently due to the irri- 
tation of the kidney produced by the excretion of oxalates and uric acid. 
The urine is of increased density, 1028, 1030 or higher, and contains 
uric acid or oxalate of lime, or both, and cylindroids. Tube-casts are 
very uncommon. The albuminuria usually disappears under proper 
diet. This condition is sometimes called " morbus Da Costse." 

It is conceded that there may be albuminuria of renal origin without 
renal disease, but the diagnosis must be by exclusion, and can be reached 
safely only after extended observation. The most important elements 
in the diagnosis are : the age of the patient, unimpaired general health, 
a specific gravity of the urine normal or above normal, the fact that 
the albuminuria is influenced by diet and exercise, and that it tends to 
disappear under suitable regimen. The prognosis is favorable. 

Mucin. Xucleo-albumin, or nucleo-proteid, is nucleic acid and 
chondro-sulphuric acid combined with a proteid. Sometimes, patho- 
logically, tauro-cholic acid enters into the combination. This is not 
true mucus, but urinary mucus. It is present in the urine in health, 
being especially abundant in women from the admixture of the vaginal 
secretion, and in excess in inflammatory conditions of the urinary tract. 
It is distinguished from albumin by the fact that it gives a precipitate 
upon the addition of vegetable acids, as acetic or citric. The precipi- 
tate is increased by removing the salts of the urine by dialysis, or by 
dilution of the urine, with two or three volumes of distilled water, 
diminishing thereby the relative proportion of salts to mucus. It is 
precipitated by dilute mineral acids, but is soluble in concentrated 
mineral acids or dilute alkalies. 

According to Roberts, the best method for the detection of mucin is 
by means of a saturated solution of citric acid, employed in the same 
manner as the contact-method of applying the nitric acid test for albu- 
min. A small quantity of the urine is first put in a test-tube, and citric 
acid allowed to trickle down the sides of the tube until it forms a dis- 
tinct layer below the column of urine. If mucin is present there will 
gradually appear an opalescent zone immediately above the layer of 
acid. Acetic acid, mixed with one-third of its volume of glycerin, 
answers admirably as a test for mucin. Sometimes, when mucin is 
very abundant, the addition of an excess of acetic acid produces a 
marked milkiness in the urine, which is not discharged by boiling the 
liquid. 

Blood. Urine containing blood is usually red in color or reddish- 
brown and opaque, but it may be chocolate-brown if the blood is present 
in large quantity and has been acted upon by the urine. Such urine 
necessarily contains albumin. 

Blood occurs in the urine from (1) diseases of the kidney and urinary 
passages, among which are Bright' s disease, acute congestion of the 



DISEASES OF THE KIDNEYS. 929 

kidney, renal calculus, cancer, tuberculosis ; from ureteritis, cystitis, and 
urethritis, and from injuries ; (2) from general diseases, such as the 
eruptive and intermittent fevers, scurvy, purpura, peliosis rheumatica, 
leucocythaemia, cholera ; (3) from adjacent organs, as in menstruation 
and hemorrhage from the uterus ; (4) from the toxic action of drugs — 
cantharides, turpentine, and other violent irritants of the kidney ; (5) 
vicariously — occasionally menstruation fails to occur and hematuria 
replaces it. The same is true of bleeding from piles. Latour has 
reported a case of asthma which subsided suddenly upon the appear- 
ance of hematuria. 

The chemical tests for blood are the same as those for its coloring- 
matter, and will be referred to under Haemoglobin. 

Haemoglobin. Haemoglobin is, of course, present whenever blood 
is, but sometimes it occurs independently of hematuria. Thus, it is 
found in grave infectious diseases, as the result of toxic action of drugs, 
such as carbolic acid, and in an independent disease known as parox- 
ysmal haemoglobinuria. A suitable test consists in adding one or two 
drops of freshly prepared tincture of guaiac to about one drachm of 
urine, then shaking the mixture and adding several drops of a solution 
of hydrogen peroxide. If blood-coloring matter be present, a beautiful 
blue coloration will be produced. 

The same test answers for methaemogiobin and haematin. 

Paroxysmal Hcemoglobinuria. The urine contains blood, or only 
the coloring-matter of the blood is present. Haemoglobinuria is more 
frequent in adult males ; it may be excited by a cold bath, or exposure 
to cold, or by exertion. It is sometimes associated with Raynaud's 
disease. The attacks come on suddenly, often preceded by chills. 
Sometimes fever accompanies the disease. Vomiting and diarrhoea 
occur with haemoglobinuria. Pain in the loins is sometimes com- 
plained of. The paroxysm may last a day or two, or two or three 
paroxysms may occur in the course of twenty-four hours. 

Albumose (Proteoses, propeptone or Meissner's peptone). Formerly 
the reactions which we know now determine the presence of the albu- 
moses were thought to indicate the presence of peptone. The latter 
substance is extremely rare. Recent chemical investigations show 
that that which was called peptonuria is truly albumosuria. Albu- 
mose has been found in the urine in osteomalacia and diseases of the 
medulla of bone and in myxoedema. When persistent it is in all proba- 
bility due to multiple tumors of the bones or to myxoedema. The 
albumosuria may be considered as primary. Transitory albumosuria 
is found in pneumonia, deep-seated suppuration, meningitis, and in der- 
matitis, intestinal ulcer, measles, scarlatina, and mental diseases. Its 
frequent occurrence renders its presence of not much diagnostic value. 
According to von Jaksch, its presence may indicate that a suppurative 
process exists. In the diagnosis of epidemic cerebro-spinal from tuber- 
cular meningitis transitory albumosuria speaks for the former if no 
ulcerative tuberculous process exists elsewhere. Urine containing it 
does not respond, at first, to the heat and nitric-acid test, but on cooling 
a precipitate forms which responds to the biuret test. (In this test the 
urine is first treated with about one-half its volume of sodium hydrox- 

59 



930 SPECIAL DIAGNOSIS. 

icle solution, and then a 1 per cent, solution of cupric sulphate is added, 
drop by drop. If albumose is present, the resulting cupric hydroxide 
is dissolved, and the fluid becomes of a violet-red color.) The proba- 
bility of the presence of albumose is strengthened if a turbidity occurs 
with the acetic acid and potassium ferrocyanide test (acetic acid, specific 
gravity 1064, to which a few drops of a 10 per cent, solution of potas- 
sium ferrocyanide have been added), and also with the biuret test, 
applied directly to the urine itself. Albumin also responds to this test. 

The best test for albumoses is that of Hofmeister, modified by Sal- 
kowski. Twenty to fifty c.c. of urine are acidified with acetic acid and 
then added to an equal quantity of a saturated solution of common salt, 
boiled and filtered. In this manner the urine is freed from albumin ; 
the albumin remaining as a filtrate while the albumose is re-dissolved. 
The filtered fluid containing the albumose is placed in a beaker and 
a few drops of HC1 added. A solution of phosphotungstic acid is 
added and the precipitate consolidated by heat into a coherent mass. 
Then pour off the supernatant fluid ; wash the precipitate with water 
and dissolve in a solution of soda (sp. gr. 1.16), which is added, drop 
by drop, until dissolved. If the solution is blue it is to be gently 
heated, to decolorize. A few drops of a 1 per cent, solution of sul- 
phate of copper is added to the soda solution. If a red or violet color, 
the biuret reaction results, albumose is present. 

The late Dr. N. A. Randolph suggested the following test, which is 
given by Tyson : To 5 c.c. of urine, which must be cold and faintly 
acid, add two drops of a saturated solution of potassium iodide and 
then three or four drops of Millon's reagent. If albumoses or bile- 
acids are present, a yellow precipitate falls. If the yellow precipitate 
does not respond to the test for bile-acids, it is due to albumose. 

Sugar (Glucose). Next to albumin, sugar is the most important 
abnormal constituent of the urine. It is not present in normal urines 
in quantities that can be detected by ordinary clinical methods. The 
best tests for its detection are Fehling's test and the fermentation test. 

Fehling's Test. Fehling's solution is prepared by dissolving 34.652 
grammes of pure crystallized cupric sulphate in about 200 c.c. of water. 
About 173 grammes of sodic potassium tartrate (Rochelle salt) are dis- 
solved in about 480 c.c. of sodium hydroxide solution of 1.14 specific 
gravity. The cupric sulphate solution is added slowly to the sodic 
potassium tartrate solution, stirring constantly until all of the cupric 
sulphate solution has been added. The bluish-white precipitate of 
cupric hydroxide which first forms will, on stirring the liquid, be 
completely dissolved. The blue liquid is then diluted with water to 
exactly 1000 c.c. One c.c. of this solution will be reduced by 0.005 
of a gramme of glucose. Fehling's solution is prone to decomposition, 
and as much as possible, to avoid the occurrence of decomposition, it is 
best to keep the cupric sulphate and sodic potassium tartrate solutions 
in separate bottles closed with rubber stoppers. To accomplish this, 
the 34.652 grammes of cupric sulphate are dissolved in water and 
diluted to 500 c.c, and the sodic potassium tartrate is dissolved in 
water and diluted to 500 c.c, and the two solutions preserved in sepa- 
rate bottles closed with rubber stoppers. The solution, prepared in 



DISEASES OF THE KIDNEYS. 931 

this manner, is made ready for use by mixing one volume of the cupric 
sulphate solution with an equal volume of the sodic potassium tartrate 
solution. The resulting liquid will be Fehling's solution, and 1 c.c. of 
it will be equal to 0.005 of a gramme of glucose. 

Certain precautions are necessary in the application of this test. 

1. Any albumin present must be removed by boiling and filtration. 

2. The Fehling solution, diluted with 4 to 5 volumes of water, must 
be boiled first and the urine added to it ; the urine must not be boiled 
first and the Fehling solution added to it. Boiling the reagent first is 
a test of its stability : if a precipitate occurs, the solution is unfit for use. 
As Wormley correctly says, a precipitate is more likely to occur when 
the Fehling solution has been diluted with four or five times its volume 
of water than on boiling the undiluted solution. 3. Prolonged boiling 
is to be avoided. The solution is to be heated to the boiling-point 
and the urine then added ; if no precipitate indicating sugar occurs 
until urine is added almost equal in volume to that of the reagent, the 
mixture should be again heated to the boiling-point and then set aside. 
4. AYhen the earthy phosphates are abundant, it is well to get rid of 
them by adding a small quantity of sodium hydroxide and filtering 
before applying the sugar test. 5. Changes in color may occur from 
the presence of urea, uric acid, and extractives. These changes can 
be obviated, when necessary, by the method proposed by Seegen, who 
recommends repeated filtering through animal charcoal until the urine 
is rendered colorless. Fehling's test is then applied to the filtered urine. 

The method of applying Fehling's test is as follows : Fehling's solu- 
tion is poured to the depth of about one-quarter of an inch into a test- 
tube, and diluted with four or five times its volume of water, and heated 
until it begins to boil ; then one or two drops of the suspected urine are 
added. If it be ordinary diabetic urine, the mixture, after an interval 
of a few seconds, will suddenly turn to an intense opaque yellow or 
reddish-brown color, and in a short time an abundant yellow or reddish- 
brown precipitate falls to the bottom. If, however, the quantity of 
sugar present be small, the suspected urine is added more freely, but 
not beyond a volume equal to that of the diluted Fehling's solution 
employed. In this latter case it is necessary to raise the mixture once 
more to the boiling-point. It is then allowed to cool slowly. If no 
cuprous oxide has been thrown down when the liquid has become cold, 
then the urine may be pronounced sugar-free. 

Sir William Roberts has recently point( d out the value of repeated 
filtration through animal charcoal of urine which reacts doubtfully to 
the test for sugar ; by this filtration the urates, uric acid, and other 
normal constituents of the urine, which have more or less power of 
reducing Fehling's solution, are removed, while the sugar passes 
through and is found in undiminished quantity in the filtrate. 

The test is made as follows : A test-tube is charged with Fehling's 
solution to the depth of about one-quarter of an inch, diluted with four 
or five times its volume of water, and brought to the boiling-point ; the 
urine, filtered through charcoal, is added to the depth of about two 
inches, and the two fluids mixed. The flame of a lamp is then applied 
to the upper half of the column of liquid, and this is boiled for a couple 



932 SPECIAL DIAGNOSIS. 

of seconds. If sugar is present, the upper half loses its blue color and 
assumes a yellowish tinge, and the earthy phosphates which are thrown 
clown in light flakes by the alkali of the test are tinted more or less of 
a gold color by the precipitation on them of the cuprous oxide. 

The Fermentation Test. This is based upon the fact that sugar by 
fermentation with yeast breaks up into alcohol and carbon dioxide. 
It is a reliable but not a very delicate test for sugar. 

A piece of yeast-cake the size of a pea is added to a test-tube full of 
urine. The open end of the tube is inverted under water in a saucer 
or beaker. If sugar is present in amounts larger than two and a half 
grains to the ounce, bubbles of carbon dioxide collect at the upper part 
of the tube after standing twelve hours in a temperature of about 90° P. 

The Phenyl-hydrazin Test. Von Jaksch believes this test to be a very 
accurate one. About two grains of phenyl-hydrazin hydrochloride and 
about three grains of sodium acetate are put into a test-tube half -full of 
water. The contents of the tube are heated and the tube filled with the 
suspected urine. The tube is kept for fifteen or twenty minutes in 
boiling water, and then put in a vessel of cold water. When a large 
amount of sugar is present a deposit of yellow, needle-like crystals is 
visible to the naked eye ; but when only a small amount is present, the 
sediment must be examined under the microscope. The crystals appear 
singly, or in sheaves and fine radii. Yellow plates and brown balls do 
not indicate sugar. (Plate XLVI.) 

Quantitative estimation of sugar can be made with Fehling's solution 
by using a burette and measured quantities of urine and reagent. 
Wormley recommends a method which answers very well for office- 
use : One cubic centimetre of Fehling's solution is diluted in a large 
test-tube with four cubic centimetres of distilled water, and boiled. 
One-tenth of a cubic centimetre of the suspected urine is then added 
from a graduated pipette. Heat is then applied, the precipitate watched, 
and then another one-tenth cubic centimetre added, and heat again 
applied. The addition of one-tenth of a cubic centimetre, followed by 
heat, is continued, until it is found, after proper subsidence, that all 
the color is removed from the diluted Fehling's solution. If in doing 
this one cubic centimetre of urine has been added, it will have contained 
just 0.5 per cent, of sugar. If more than one cubic centimetre, it will 
have contained less than 0.5 per cent. If exactly two cubic centimetres 
are used, it will have contained exactly 0.25 per cent. If one-tenth of 
a cubic centimetre has been used, the urine will have contained 5 per 
cent, of sugar. If the quantity of sugar in the urine is large, the urine 
should first be diluted with a measured volume of water, allowance 
being made for this in the estimation. 

When the quantity of sugar is relatively large fermentation is the 
simplest and most trustworthy method. Roberts has shown that 
saccharine urine loses by fermentation one degree in density for every 
grain of sugar contained in an ounce of urine. For example, if the 
urine before fermentation had a specific gravity of 1040, and after fer- 
mentation a specific gravity of 1010, then the urine contained 30 grains 
of sugar to the ounce. In the application of this method, about four 
ounces of diabetic urine are put in a twelve-ounce bottle, and a piece 



PLATE XLVJ 







.A v 



Crystals of Phenyl-glueosazone. 

(Oc. 4, Obj. D.) Drawn by J. D. Z. Chase. 



DISEASES OF THE KIDNEYS. 933 

of Vienna yeast, about the size of a pea, is broken up and then added 
to it. This bottle is closed with a perforated cork to allow the C0 2 
to escape, and stood aside in a warm place to ferment. Beside it is 
placed a tightly corked four-ounce bottle filled with the same urine, 
but without any yeast. In about twenty-four hours the fermentation 
will have ceased. The specific gravity of the fermented urine is then 
taken and also that of the unchanged urine. Every degree of loss in 
density represents one grain of sugar per ounce of urine. 

Diabetes Mellitus. The occurrence of any of the following condi- 
tions should lead to an examination of the urine for sugar, and an esti- 
mation of the quantity of urine passed in twenty-four hours, apart from 
the routine examination, which should be made in every case of chronic 
disease or of obscure acute disease : 1. Muscular weakness without 
cause. The weakness is progressive and rapidly advances to an ex- 
treme degree. 2. Emaciation. In young subjects this is rapid in 
cases of diabetes. In older patients it is not so striking, particularly 
if the gouty diathesis is present. 3. Thirst. This is a symptom 
which is of common occurrence in diabetes, and is most distressing. 
If the amount of fluids taken be compared with the amount of urine 
excreted, it will be found that the two bear a definite ratio. The thirst 
is greater immediately after meals, although the patient does not neces- 
sarily have indigestion. 4. Hunger. Excess of appetite, boulimia or 
polyphagia, also occurs in diabetes. The amount of food that is taken 
is sometimes enormous, and the ravenous way it is devoured is revolt- 
ing. 5. Loss of sexual power. 

The five symptoms just mentioned, with increased frequency in 
micturition, are the common symptoms of diabetes mellitus. They 
may develop gradually. In rare instances the onset is sudden. The 
occurrence of these symptoms should lead at once to an examination of 
the renal secretion. 

Three special characteristics of the urine are observed. A. The 
amount is increased, so that from six to ten pints, or even as much as 
thirty to forty pints, are passed in twenty-four hours. B. The specific 
gravity ranges from 1025 to 1015, and may even be higher. C. The 
presence of sugar. The sugar is detected by the ordinary tests. (See 
Examination of Urine.) In addition the urine is usually of pale color, 
of a sweetish odor and acid reaction. 

In addition to thirst and increased appetite, some gastro-intestinal 
symptoms may be of diagnostic importance. Of these, first, the appear- 
ance of the tongue is characteristic. It is dry, red, and glazed. The 
dryness is increased because of the scanty flow of saliva. The gums 
are swollen and spongy, and marginal gingivitis and stomatitis are often 
present. There are no marked dyspeptic symptoms. Constipation is of 
common occurrence. 

In diabetes other secretions diminish.. Perspirations do not occur, 
except in inflammatory complications. The skin is harsh and dry. As 
the disease progresses the heart's action becomes weak and the pulse 
frequent, with lowered tension. The temperature of the body is usually 
below normal. 

Diabetes may occur at any age, but is most frequent in adult life. 



934 SPECIAL DIAGNOSIS. 

In young adults the symptoms are more pronounced, and the duration 
shorter. In patients past middle life the disease may continue for a num- 
ber of years without marked interference with the health and nutrition. 

While the symptoms just mentioned should lead to an examination 
of the urine, diabetes mellitus may not be suspected by any of the usual 
objective or subjective symptoms. It may happen that none of these 
symptoms is sufficiently marked, and that only by routine examination 
of the urine, or by the occurrence of affections known to be associated 
with sugar in the urine, is the disease discovered. 

Of the complications which should lead to the suspicion of sugar in 
the urine the following are the most important : 

1. Cutaneous Complications. Boils and carbuncles should always 
lead to an examination of the urine. Pruritus and chronic eczema 
may have diabetes in the background. Gangrene of the extremities, 
chiefly of the feet and legs, and gangrene in other situations, is of com- 
mon occurrence in the course of diabetes. 

2. Lung-complications. Tuberculosis, both of the chronic and the 
acute pneumonic type, is frequently associated with diabetes. Lobar 
pneumonia is apt to occur. In all cases of pneumonia the urine should 
be examined for sugar. Its presence would modify the prognosis of an 
otherwise moderate case. Gangrene is likely to ensue in the acute and 
chronic lung affections. Gangrene of the lung in the course of diabetes 
may be latent, and recognized only by the odor and the character of the 
expectoration, or it may run an acute febrile course. 

3. Nervous Symptoms. Diabetic coma may develop in the course of 
the disease. In young subjects, particularly, the occurrence of coma 
should lead to a suspicion of diabetes. Such coma may occur before 
the disease has been recognized. The coma may follow an attack of 
fainting and prostration, with stupor, which deepens into complete 
unconsciousness. It may be preceded by nausea and vomiting or by 
the lung-complications previously mentioned. This form of coma is 
usually preceded by extreme dyspnoea, by agitation, pain in the head, 
and some delirium. The pulse becomes rapid and feeble, and coma 
develops gradually. For this form of coma the term acetonaimia is 
used. The breath is of a peculiar sweetish odor, due to acetone, and 
this compound is detected in the urine. Coma may occur without any 
premonitory symptoms whatsoever, the patient reeling for a short time, 
and complaining of pain in the head as if intoxicated. 

Peripheral neuritis should always lead to an examination of the 
urine. It may be limited to one group of nerves, or may be more or 
less general, with symptoms like those of locomotor ataxia, as the light- 
ning-pains, abolition of reflexes and loss of power in the extensor 
muscles. Diabetic patients are also subject to neuralgia, and to periph- 
eral hypersesthesia and paresthesia, probably due to neuritis. The 
neuritis may be so extreme as to lead to paraplegia. 

4. Eye-symptoms. A curious symptom of diabetes is the occurrence 
of cataract. This may develop at any age, and is often rapid in its 
course. Cataract or alterations of vision should always demand an 
examination of the urine. Diabetic retinitis is sometimes present. 
Atrophy of the optic nerves, or muscular insufficiencies, may take 



DISEASES OF THE KIDNEYS. 935 

place, the latter causing the pronounced symptoms of eye-strain. 
Ringing in the ears, deafness, the occurrence of acute otitis, are 
phenomena which arise in the course of diabetes. 

Diagnosis. Sugar in the urine occurs temporarily when there is 
an excess of saccharine diet, or when there is functional disorder of the 
liver. The sugar is small in amount, and the glycosuria is transient. 
The diagnosis of true diabetes is not difficult, although the disease may 
be overlooked unless the habit, previously insisted upon, of constant 
urinary examinations is fully developed. 

Indican. An excess of indican in the urine is known as indicanuria. 
The substance is detected by several methods. Jaffe's test : Equal 
volumes of hydrochloric acid and urine are mixed. By means of a 
glass pipette a solution of sodium hypochlorite is dropped into the fluid. 
An indigo-blue color is produced if indican be present. The hypochlo- 
rite must not be added in excess. A quantitative determination is 
made by the colorimetric process of Salkowski. A rough analysis is 
first made, to determine the quantity of calcium hypochlorite, which 
causes the greatest amount of indigo to unite with it. If the urine 
contains much indican, a small portion, as 2.5 to 5 c.c, is diluted with 
water to 10 c.c. If there is but little indican, 10 c.c. of the urine are 
used without dilution. An equal quantity of hydrochloric acid is 
added. To this the amount of hypochlorite solution with which, in 
the first test, indigo combined in the greatest amount is added. Then 
the liquid is neutralized with sodium hydroxide, then enough sodium 
carbonate is added to make it alkaline. The indigo-blue is thus pre- 
cipitated and collected on a filter. The precipitate is repeatedly washed 
with water until the alkaline reaction disappears. The filtrate is dried 
and extracted by heating with chloroform, until the latter no longer 
assumes a blue color. The chloroform extract is increased to a round 
number of c.c. by the addition of chloroform, and placed in a vessel 
with parallel sides. The intensity of its color is compared with a 
freshly prepared chloroform solution of indigo blue of known strength. 
To one or other of these chloroform is added until the tint of both is 
the same. The quantity of indigo-blue derived from the urine is deter- 
mined, and its percentage calculated from the intensity of color and 
strength of the solution of indigo of known strength. Five to twenty 
milligrammes of indigo-blue are passed in twenty-four hours in health. 
Indican is increased by animal diet — an increase which, under other 
circumstances, is pathological. Its presence is a sign of intestinal 
putrefaction. It may accompany a decomposition of albumin in cavi- 
ties. It is present in empyema and in puerperal peritonitis. By 
detection of its presence in these diseases cavities due to pus may be 
distinguished from those due to other causes. Indican is increased in 
acute diarrhoea and in intestinal tuberculosis. Von Jaksch states that 
large quantities of indican in the urine imply that abundant albuminous 
putrefaction or putrid suppuration is in progress in the system. It must 
not be forgotten that indicanuria will often arise in simple constipation. 

Bile -pigments and Bile-acids. Bile-pigment or bilirubin occurs 
in the urine in cases of hepatogenic and hematogenic jaundice and in 
portal thrombosis. 



936 SPECIAL DIAGNOSIS. 

Gmelin's test and its modifications are the ones usually employed. 
A small quantity of nitric acid, to which some nitrous acid has been 
added, is put into a test-tube and then gently overlaid with urine. If 
bile-pigment is present, a series of colors appear at the junction of the 
two fluids — green, blue, violet, and yellow. A green color (biliverdin) 
must be present to prove the existence of bile-pigment. 

The same test may be applied by placing a few drops of the acid 
upon one side of a plate and the urine on the other, and then allowing 
the two to run together. The play of colors takes place, as before, at 
the line of junction of the acids and urine. 

Rosenbach's modification is an improvement. About 200 c.c. of urine 
are allowed to flow through pure white filter-paper, and then a drop of 
nitric acid is placed upon the paper saturated with the urine. The 
colors appear as before described. 

A very simple test consists in allowing a few drops of the acid to 
fall into a test-tube full of urine. If bile-pigment is present, a 
green color appears at the line of junction of the two fluids. This 
test may fail, however, if only small quantities of bile-pigment are 
present. 

The tests for bile-acids are either too elaborate or too unsatisfactory 
for clinical use. 

Pus. Pus is found in the urine whenever there is suppuration or 
a catarrhal condition of the genito-urinary tract. Hence, it occurs in 
abscess of the kidney, pyonephrosis, pyelitis, tuberculosis, cystitis, gonor- 
rhoea, leucorrhoea, etc. It is relatively common in women, from a 
catarrhal condition of the vulva and vaginal mucous membrane, and 
is, therefore, of less significance than in men. Urine containing much 
pus is slightly albuminous ; but frequently pus-cells are found in urine 
which gives no reaction for albumin. 

The chemical test for pus is its conversion into a tenacious (gelat- 
inous), glairy mass by boiling with caustic potash. 

Acetonuria. An excess of acetone occurs in the following diseases : 
(1) In diabetes ; (2) in cancer independent of starvation ; (3) in starva- 
tion ; (4) in certain psychoses ; (5) in auto-intoxications ; (6) in derange- 
ment of digestion ; (7) in fevers. In diabetes acetone indicates an 
advanced stage of the disease. Lieben's test for acetone is as follows : 
To several c.c. of urine a few drops of iodo-potassium iodide solution 
and sodium hydroxide are added. If acetone is in excess, the precipi- 
tation of iodoform takes plaoe, which may be recognized by its odor. 

Diaceturia. Diacetic acid is found in the urine in diabetes, in fevers, 
and in auto-intoxications. It is common with children in fever. It 
is of grave significance when in the urine of adults. Coma usually 
follows its occurrence in the urine in fevers and in diabetes. Test : A 
concentrated solution of ferric chloride is cautiously added to the urine. 
If a precipitate be formed, it should be removed by filtration and more 
ferric chloride added to the filtrate. If diacetic acid be present, the 
liquid will become claret-red in color. 

Haematoporphyrinuria. This is a rare constituent of the urine 
derived from the blood. It is said to be a form of hsematin freed from 
iron. Nakarai thinks that the occurrence of hsematoporphyrinuria is 



DISEASES OF THE KIDNEYS. 937 

constant in lead-poisoning, and occurs with some degree of frequency 
in intestinal hemorrhage. 

Alkaptonuria. The substance in the urine which has been identi- 
fied as alkapton is also known as pyrocatechin (Ebstein and Muller, 
Virchow's Archiv, Bd. lxv. s. 394), protocatechinic acid (Smith, Dub- 
lin Journ. Med. 8c, 1882, vol. i. p. 465), urrhodinic acid (Kirk, British 
Medical Journal, London, 1886, vol. ii. p. 1017), glycosuric acid (Mar- 
shall, Medical News, Philadelphia, 1887, p. 35), uroleucinic and uro- 
xanthinic acids (Kirk, British Medical Journal, London, 1888, vol. ii. 
p. 232), and homogentisinic acid (Baumann and Wolkow, Ztschr. f. 
physiol. Chem., Strassburg, Bd. xv. s. 228). It reduces copper, as 
does glucose, and its occurrence is of interest, because the presence of 
the substance has led to the diagnosis of glycosuria in many instances, 
in consequence of which persons have been refused life insurance. 
The urine containing this substance deepens in color on exposure to 
air. It is of a peculiar aromatic odor, and reduces cupric salts rapidly. 
There is, however, no reaction to the fermentation test, to Bottger's 
bismuth test, or to phenylhydrazin, and no deviation of the rays of 
polarized light. The urine does not contain bile-pigment. It is of 
normal specific gravity, and becomes very dark on the addition of an 
alkali or of a temporarily bluish-green color with perchloride of iron. 
Ammonia nitrite of silver is instantaneously reduced when added to 
the urine with a deposit of metallic silver. 

Alkaptonuria is usually congenital. Several members of the same 
family will have it. No symptoms attend the condition. 

Note. — Serum-globulin is converted into a coagulated proteid when 
heat is applied or concentrated nitric acid added to a solution. Globu- 
lin is soluble in dilute salt solutions. If urine, rich in globulin, is 
added, drop by drop, to a large volume of distilled water, the globulin 
is precipitated as the percentage of salt is reduced by dilution. Globu- 
lin is also precipitated by dialysis. If a portion of urine containing 
globulin is saturated with magnesium sulphate or half saturated with 
ammonium sulphate, globulin is precipitated. 

Hills' describes the method as follows : " 25-50 cubic centimetres 
of the urine are made neutral or slightly alkaline with ammonium 
hydroxide, and the precipitated phosphates removed by filtration. An 
equal volume of a saturated solution of ammonium sulphate is then 
added, the mixture shaken, and allowed to stand for some time, and 
finally filtered. The precipitate is washed with a half-saturated solu- 
tion of ammonium sulphate for the removal of the last traces of albu- 
min and the filtrate and precipitate tested for albumin and globulin 
respectively, as previously described. The formation of a precipitate 
upon the addition of either magnesium or ammonium sulphate is not 
in itself evidence of the presence of globulin/' 

Microscopical Examination of the Urine. Microscopical examina- 
tion of the urine is chiefly concerned with the sediments, and these are 
conveniently divided into the organized and unorganized. 

1 Boston Medical and Surgical Journal, 1899, vol. cxli , No. 6. 



938 



SPECIAL DIAGNOSIS. 



The organized deposits in the urine are blood, pus, mucus, epithelium, 
casts, spermatozoa, micro-organisms, cancerous and tuberculous matter, 
entozoa. 

The unorganized deposits are uric acid and its compounds, oxalate and 
carbonate of lime, phosphates, leucin and ty rosin, cystin and cholesterin. 

Normal urine forms a slight sediment, consisting of epithelium from 
different parts of the genito-urinary tract, principally from the bladder 
in males, and from the vagina and bladder in females. There are also 
some crystals of the different urinary salts, sometimes mucus and a few 
white blood-cells, and, if the urine has stood a while, especially if alka- 
line, more or fewer bacteria. It may accidentally contain extraneous 
matter, derived from the vessel which contains it or from the air. (Fig. 
206.) 

Fig. 206. 




Extraneous matters found in urine: a, cotton-fibres; b, flax-fibres; c, hairs; d, air-bubbles! 
e, oil-globules ; /, wheat-starch ; g, potato-starch ; h, rice-starch granules; i, i, i, vegetable tissue ; 
k, muscular tissue ; I, feathers. 



The centrifugal machine has now become an important adjunct to 
the rapid and accurate microscopical examination of the urine. There 



DISEASES OF THE KIDNEYS. 939 

are now numerous varieties to be secured at the instrument-stores, some 
of which are devised solely for urinary examination, while others have 
additional apparatus for examination of the blood and sputum. The 
majority of them are revolved by hand. Electricity can be readily 
applied to any of them and labor be saved by such a device. The 
advantages of centrifugal force over the older gravity method employed 
in microscopical examination are marked. Some few of them can be 
briefly outlined : 

1. Centrifugalization secures complete, rapid, and concentrated sedi- 
mentation. It is, therefore, best suited to microscopical diagnosis. 

2. Casts or other organic material, if present, can be studied care- 
fully before they are macerated or partially destroyed by bacteria or 
changed by the deposition of amorphous or crystalline material. This 
is a most important aid to correct diagnosis. 

3. Crystals, if present at the time of urination, can be discovered and 
differentiated from those that normally crystallize out after some hours. 

4. Certain bodies, hyaline casts, for instance, because of their rather 
light specific gravity, do not settle on the simple standing of the urine, 
and thus escape detection. These with all other substances are thrown 
down with the centrifugal machine. 

5. Bacteria are discovered with greater ease, especially the tubercle 
bacillus. 

The method commonly used for the examination of the urinary sedi- 
ment is as follows : The urine for examination (the chemical analysis 
having previously been made) is decanted until there remains but a 
small amount in the bottle, which amount contains any sediment 
already formed, and heavier organic materials. This is then poured 
into one of the tubes of the centrifugal machine to within one-half 
inch of the top ; if but one specimen of urine is to be examined, fill 
both tubes with the same urine. If there is not sufficient urine to do 
this, fill the remaining tube or tubes with water. It is well to mark 
the external metal shields of the tubes with a figure, say 1 and 2, or a 
and b, so that the urines, if different specimens, may not become con- 
fused. 

The tubes are then rapidly revolved for three minutes, then removed 
from the machine and a few drops of the sediment withdrawn with a 
pipette and placed upon the slide for examination under the microscope. 
It is necessary to remember that care must be exercised in removing 
this sediment from the tube. The straight glass pipette without a 
pointed end seems to give the best results in securing the sediment. 
The finger is placed upon one end, the pipette inserted to the bottom 
of the tube and the finger is then elevated just enough to secure a few 
drops of the sediment that has been cast down by centrifugalization. 
If the urine contains but the normal mucous cloud, a very small whitish 
sediment or cloud is found at the bottom of the tube. If oxalate of 
lime is present, a small filmy whitish sediment is seen. The sediment 
of amorphous urates is pinkish, fawn, or salmon color. Uric acid 
appears as a " brick-dust " sediment. Pus produces a heavy yellowish 
sediment ; phosphates a heavy white sediment, which is sometimes 
yellowish-white from admixture with leucocytes. Blood in small 



940 



SPECIAL DIAGNOSIS. 



quantities produces a rather characteristic brownish deposit. Large 
amounts of blood appear as reddish coagulae at the bottom of the tube. 
With some of the centrifugal machines the various urinary salts and 
the amount of albumin present can readily be estimated. Such instru- 
ments are provided Ayith graduated tubes, in which the urine and the 
necessary reagents are put and the resulting precipitate rapidly cast 
down. 

Fig. 207. 




Cellular elements from the urine. 1, squamous epithelium ; 2, red blood-corpuscles ; 3, poly- 
nuclear leucocytes ; 4, transitional cells ; 5, epithelium from the kidneys ; 6, epithelium from the 
bladder ; 7, micrococcus aurese ; 8, yeast-fungi. 

In this manner Purdy estimates the chlorides, sulphates, and phos- 
phates, and also the amount of albumin most satisfactorily. It is ques- 
tionable, however, whether the estimation of the salts is accurate. 

Organized Sediments. Blood. If the blood comes from the kid- 
ney, it is usually intimately mixed with the urine, which remains of a 
red or reddish-brown color, and contains possibly tube-casts and renal 
epithelium. The blood-cells appear singly, have frequently lost their 
haemoglobin, and hence look like pale-yellow disks. (See Fig. 207.) 

Sometimes blood coagulates in the ureters, and long, cylindrical 
plugs are passed, causing symptoms resembling those of renal colic. 
When blood comes from the bladder or neck of the bladder (fissure) 
there are symptoms of frequent micturition, of acute pain and tenes- 
mus, and the blood is not intimately mixed with the urine. When 
from the neck of the bladder, it often occurs in a few r drops at the end 
of micturition, accompanied with great pain and a sense of faintness. 
Intermittent hematuria, according to Von Jaksch, points directly to 
calculus or tumor of the bladder. 

Blood-cells, when unaltered, are unmistakable, on account of their 
well-known biconcave appearance. When they haye lost their color- 
ing-matter they appear as circular, very pale disks, with extremely 
faint outline and feeble refractive power. Absence of a nucleus serves 



DISEASES OF THE KIDNEYS. 941 

to distinguish thern from yeast-spores, and the latter, moreover, are 
often oval in shape. They are less likely to be confounded with the 
ovoid and circular shapes of oxalate of lime crystals, because the latter 
are not common, and can be seen usually in their more common forms 
as octahedra and dumb-bells in the same urine. 

Pus. The sources of pus in the urine have been referred to already. 
The pus-corpuscle is an opaque, spherical, granular cell, usually some- 
what larger than are blood-cells. In dilute urine, or urine to which 
water has been added, it swells sometimes to twice its original size. 
At the same time, it becomes less granular, and two, three, or four 
nuclei may appear. In concentrated urines the pus-cell is small. The 
addition of acetic acid also causes it to swell, and brings out the nuclei 
more distinctly and rapidly. Sometimes the pus-cells are discrete, 
sometimes in dense clumps, and sometimes nothing but a dense mass 
of pus-cells appear in the field of the microscope. 

It cannot be decided from microscopic examination whether a cell 
is a pus-corpuscle, a mucus-corpuscle, a white blood-cell, or an inflam- 
matory leucocyte. It must be a matter of inference from the general 
characters of the urine. If red blood-cells are also present, the proba- 
bility of finding white blood-cells is increased, but pus-cells are not 
necessarily excluded. So, too, if much mucus be present in the urine, 
the doubtful cell may be a mucus-corpuscle. Some clue to the source 
of the pus can be obtained from the urine itself. Urine containing pus 
from the kidney is usually acid, whereas in cystitis it is alkaline, and 
almost always contains phosphates, mucus, and abundant bacteria. 
Again, pus from the kidney, or kidney pelvis, is apt to vary greatly in 
amounts, or be discharged intermittently ; and the urine, when filtered 
free from pus-cells, is usually still albuminous. Renal epithelium and 
casts may also be found. 

Casts. Casts are the most important of the urinary deposits. They 
vary greatly in number and size. Sometimes in acute nephritis they 
form a considerable part of the sediment, but usually they have to be 
sought for carefully and patiently. A few words as to the method of 
examining for them may not be superfluous. 

Sedimentation by the centrifugal machine is now much in vogue. If 
the centrifugal machine cannot be employed, proceed as follows : 

Six or eight ounces of the urine to be examined should be allowed 
to settle in a bottle as soon after being passed as possible. The bottle 
should be tightly corked, because urine exposed to the air decomposes 
very quickly ; it should be sent to the person who is to examine it as 
soon after being passed as possible, in order that an examination may 
be made before fermentative changes spoil it for trustworthy analysis. 
After standing twelve, or preferably twenty-four hours, nearly all of the 
solid matter will have collected at the bottom of the bottle. The super- 
natant clear fluid can nOw be poured off, and the lower portion of the 
urine and the sediment poured into a conical subsiding-glass. If the 
urine is febrile, there may be by this time a large deposit of amorphous 
urates, which will obscure the search for casts ; they may be dissolved 
by gentle heating without destroying the casts, and the clear urine 
again allowed to settle for a few hours. So, too, if phosphates are 



942 



SPECIAL DIAGNOSIS. 



abundant, they should be gotten rid of by gentle heating and acidula- 
tion with two or three drops of dilute acetic acid. 

After the urine in the conical subsiding-glass, which will not now 
amount to more than an ounce or two, has stood for a few hours, any 
casts that may be present will have fallen into the bottom. If the 
urine is very concentrated (1030 or more), epithelium, blood, and casts 
will be suspended longer ; hence, it may be well to dilute the urine 
before allowing it to settle. 

A glass tube, with an internal diameter of about one-eighth of an 
inch, and with one end drawn out fine, is the most convenient thing 
for collecting the sediment. The ordinary glass pipette, with a rubber 
suction-bulb at one end, commonly known as a " medicine-dropper," 
sometimes answers admirably. If the common glass tube is used, the 
forefinger of the right hand should be placed over the open upper end, 
and the fine lower end passed down to the bottom of the glass. The 
finger is then removed sufficiently to permit a few drops to be sucked 
in. The same thing is attained if the finger is entirely removed as soon 
as the point on the tube reaches the bottom of the conical glass ; but 
in that case more than the lowest layers of the sediment or urine are 
sucked up, and hence all but a few drops should be allowed to flow out 
when the tube is removed from the urine. In this way the drops pre- 
served for microscopical examination will contain the sediment from 
the very bottom of the glass. In this sediment, in pale urines free 
from much urates, phosphates, and pus, the casts will be found, if any 
are present in the urine. It is most important to examine the bottom 
layers of the sediment when the latter is scanty, or when phosphates 
or urates have begun to precipitate after the urine has been standing 
some time. If the urine is already cloudy with phosphates, urates, or 
pus, when it is put aside to settle, any casts that may be present will be 
carried down with the heavier sediment, and will be found intimately 
mixed with it, or even on top of the other sediment. 

Fig. 208. 





Epithelial and hyaline casts. 



The few drops preserved for microscopical examination are now depos- 
ited on several slides, without a cover-glass, and examined carefully 
for casts under a power of 50 to 60 diameters. Casts may be numerous, 



DISEASES OF THE KIDNEYS. 



943 



so that nearly every field contains one dozen or more, or they may be 
very few, not more than one or two being found on a slide. The best 
routine method for microscopical examination is as follows : place a 
few drops of the urinary sediment upon the slide ; spread the drops in 




Hyaline casts and cylindroids in hypostatic congestion of kidney. Low power. 

a thin layer ; use no cover-glass ; examine with the low power — a diam- 
eter of 50 — with a small amount of light ; the whole slide can be care- 
fully searched in three minutes, and casts discovered can be minutely 

Fig. 210. 




Hyaline casts from a case of acute nephritis. 1, plain hyaline cast ; 2, granular deposit on hyaline 
cast; 3, cellular deposit (blood and epithelium). 

studied with the higher power. When but few casts are present, several 
slides can be rapidly examined with the low power, and an accurate 
estimation of the number made. 



944 



SPECIAL DIAGNOSIS. 



All the pipettes used in examining urine must be kept clean. They 
should be allowed to stand in water which is frequently changed, and 
carefully rinsed in running water before being used. 

Tube-casts usually indicate acute or chronic nephritis ; but they are 
sometimes found in cases of renal calculi ; in icterus, usually without 
albuminuria ; in diabetes, and sometimes in secondary congestion of 
the kidney. 

Fig. 211. 




Granular casts. 



Several varieties of casts are found. 1. Hyaline casts, as their name 
implies, are clear, translucent bodies, which refract light so slightly that 
they are easily overlooked. They have well-defined margins, the ends 
being frequently rounded ; they are rarely very long, and are straight, 
or but slightly bent. They are rarely equally translucent throughout ; at 
some part more or less granulation will generally be found. They 
vary in diameter from that of a white blood-cell to six or eight times 
as large. They can be stained, and so rendered more distinct, by 
allowing a drop of gentian-violet solution to flow in under the edge of 
the cover-glass. (Figs. 209 and 210.) 2. Granular casts are hyaline 
casts which appear granular either from some deposit on their surface 
or from a granular change of the cast itself. When the granulation 
does not interfere with the translucency the casts are described as 
" pale " or " slightly " granular ; and when they become very dark, so as 
to resemble closely a blood-cast, they are called '" dark " or " opaque " 
granular casts. (Plate XLVIL, Fig. 1, 1 ; and Figs. 210, 211.) 3. 
Waxy casts appear to the eye to be more solid in structure than the 
hyaline casts ; they also appear more cylindrical in form, are more or 
less yellow in color, and are apt to be larger than hyaline casts. (Plate 
XLVIL, Fig. 1, 2.) 4. Fatty casts are hyaline or faintly granular 
casts on which are deposited, in spots, minute oil-drops. They are 
sometimes called "oil-casts" if the oil-drops are very abundant. (Fig. 
212.) 5. Ill o< >(!-<■( i sts are either made up of a mass of blood-cells pressed 
together into a cylindrical shape, or, more frequently, a hyaline cast is 



PLATE XLVII 



2 









1. Hyaline Casts with Granular Matter and Epithelial Cells 
deposited upon them. 2. Amyloid (waxy) Cast. 

(Oc. 4. ob. D.) Drawn by J. D. Z. Chase. 



u 



FIG. 2. 



^ 






r'A 






^ ! 






® 

^ 






1' ' 



Blood-easts from Case of Acute Nephritis. 

(Oc. 4. ob. D.) Drawn by J. D. Z. Chase. 



DISEASES OF THE KIDNEYS. 



945 



studded with blood-cells. (Plate XLVIL, Fig. 2.) 6. Epithelial casts 
sometimes seem to be composed entirely of epithelial cells closely packed 
together. Such casts are relatively rare, and very beautiful. Ordi- 
narily, just as in the case of blood-casts, an epithelial cast consists of 



Fig. 212. 




Fatty casts from a case of chronic parenchymatous nephritis. 

a hyaline cast more or less covered with renal epithelium. (Plate 
XLVIL, Fig. 1, 1; and Fig. 208.) 7. Dr. George Johnson has 
described casts composed of j9 its-corpuscles. In two cases in which 
they were found in the urine the patients were found at the autopsy to 



Fig. 213. 




Cylindroids. 



have multiple abscesses of the kidney. 8. Cylindroids are very common. 
In general appearance they resemble hyaline casts ; but they are apt to 
be much longer, bent, twisted or split, and to have, on close examina- 

60 



946 



SPECIAL DIAGNOSIS. 



tion, a striated or finely ribbed appearance. Moreover, the diameter 
of the cast frequently varies greatly at different points ; sometimes it 
appears constricted in several places, and in other cases one end tapers 
off into a thread. Often cylinclroids consist of fine, narrow, ribbon-like 
threads. (Figs. 209 and 213.) 

Spermatozoa. Spermatozoa are easily recognized by their tadpole 
shape and by the vibratile motion of their long, delicate tails. They 



Fig. 214. 




Human semen, a, spermatozoa ; b, cylindrical epithelium ; c, bodies enclosing lecithin gran- 
ules ; d, squamous epithelium from the urethra ; d', testicle-cells ; e, amyloid corpuscles ; /, sper- 
matic crystals ; g, hyaline globules. (Von Jaksch.) 

are found in the urine of both sexes after sexual intercourse. (Figs. 
214 and 215.) 

Many continent men have occasionally nocturnal emissions, accom- 
panied by erections and erotic sensations. These cannot be looked 
upon as abnormal, and they are compatible with robust health. There 
are other persons, neurotic, anaemic, and generally constipated in habit, 
who have emissions at night two or three times a week, of which they 
are unconscious until they wake and find themselves wet. Semen may 
also be lost during micturition and defecation, especially when much 
straining is required. Such a condition (spermatorrhoea) is abnormal. 
It is due to general nervous and muscular relaxation, associated with 
nervous dyspepsia and anaemia, and aggravated by sedentary life, con- 
stipation, and the reading of salacious literature or the cultivation of 
erotic thoughts. In young men, it sometimes follows habits of mastur- 
bation, which have been broken up but have left behind a hypersesthetic 
condition of the prostatic portion of the urethra, with or without dila- 
tation of the orifices of the ejaculatory ducts ; or a stricture of gonor- 
rhoea! origin may be its cause. Students and overworked and over- 
strained business and professional men are the ones most frequently 
affected. 

However caused, the condition is apt to beget a most distressing state 
of despondency, in which the patient imagines all possible ills, and is 
Liable to drift into a hysterical, melancholic, even suicidal frame of 
mind, and so falls a victim to quacks. 

Epithelium. Epithelium from the kidney, bladder, and genito- 
urinary passages occurs in the urine. Epithelial deposits in male urine 
are very scanty, unless there is some disease of the kidney or bladder, 



DISEASES OF THE KIDNEYS. 947 

or a catarrhal condition of the prostatic urethra, such as is left from 
an old gonorrhoea. On the other hand, considerable epithelium may 
be normally present in the urine of Avomen, being derived principally 
from the vagina and bladder. 

Vaginal epithelium consists of large, flat pavement-cells, and is 
readily distinguished. 

Fig. 215. 




Spermatozoa from urine. 

The type of epithelium of the kidney, kidney pelvis, ureter, and 
bladder is the same, and it is not possible to distinguish with certainty 
the cells which come from each. If the cells are scanty, Von Jaksch 
thinks they come from the ureter. He has found them in moderate 
quantities and superimposed upon one another. 

Renal cells closely resemble the oval polygonal cells from the deeper 
layers of the bladder, but they have a relatively larger nucleus. (See 
Fig.^ 207.) 

Lipuria. Oil is found in the urine in fatty degeneration of the 
kidney and its epithelium, and occasionally in the urine of those who 
are taking cod-liver oil, and in calculous disease of the pancreas. 
Tyson suggests that it may come from cystic cheesy degeneration of the 
kidney. 

It is also found in chronic nephritis, in phosphorus-poisoning, and in 
diabetes mellitus, as well as in chyluria. The urine is turbid, but 
clears when agitated with ether. The fat may be separated by a sedi- 
mentator, and can be recognized by its refractive properties. 

Staining for Fat. Reecler recommends Soudan Three for staining 
human secretions and excretions, to determine the presence of fat. 
Large fat-droplets take a bright red, and small droplets a yellow or 
orange color. Fat can thus be demonstrated in the blood in lipjeroia, 
lipuria, and chyluria. By this method fat can be demonstrated in the 
stomach-contents and in the feces of adults with jaundice. A saturated 
solution of Soudan Three in 96 per cent, alcohol is employed. Equal 



948 SPECIAL DIAGNOSIS. 

parts of this solution and 96 per cent, alcohol are added to the urine. 
In urinary sediments the fat-droplets in casts stain a scarlet red. 

Chyluria. This is a more or less milky condition of the urine, due 
to the presence of fat, which probably gains entrance to some part of 
the urinary tract by rupture of the lymphatic vessels. A case has been 
reported by Saundby, in which a young'unmarried girl, being pregnant, 
compressed her abdomen so much, in order to conceal her condition, 
that oedema of the legs, thigh, vulva, and lower parts of the abdomen 
resulted. After her confinement the urine became milky, and remained 
so for many days. It contained fatty matters and cholesterin, but no 
albumin or sugar. 

Fat and albumin appear at the same time in some diseases. They 
recur at long intervals. Red and white blood-corpuscles are also found 
in small amounts. The urine coagulates on standing, or gelatinizes. 

Parasitic chyluria is due to the filaria sanguinis hominis, whose 
embryos obstruct the lymphatics. The latter may be found in the 
urine. 

Entozoa. The most common is the echinococcus or hydatid. When 
this infects the kidney or urinary vessels, hooklets and even cysts have 
been passed in the urine. The disease is, of course, extremely rare in 
this country. 

The filaria sanguinis hominis, which causes parasitic chyluria, is occa- 
sionally found in the urine. (See Filaria.) 

The Bilharzia hwmatobia sometimes lodges in the urinary tract and 
causes hematuria. It is peculiar to Egypt. 

Distoma Haematobium. Common in Egypt and Abyssinia. Eggs 
collect in great masses in the urinary passages, and lead to inflamma- 
tion, ulcers, stenosis, etc. Eggs found in the urine alone make the 
diagnosis possible. 

Strongylus Gigas. Very rare. Symptoms of pyelitis. (The parasite 
is of the size of an earth-worm.) 

Intestinal worms may creep into the bladder through fistulous or 
other openings, and be discharged through the urethra. 

Micro-organisms. Normal urine contains no micro-organisms at the 
time it is voided. As the result of exposure to air, however, they may 
develop in great abundance. The non-pathogenic organisms found are 
classed as mould-fungi (hyphomycetes), yeast-fungi (blastomycetes), and 
fission-fungi (schizomycetes). 

Mould-fungi, according to Yon Jaksch, are rarely found in foul 
normal urine. Yeast-fungi are also rare in normal urine. Fission- 
fungi are found in urine undergoing ammoniacal decomposition. 

Sarcinse, usually smaller than those of the stomach, are occasionally 
met with — especially, according to Roberts, where there is some dis- 
order of the urinary organs, renal pains, painful micturition, cystitis, etc. 

Under the name baderiuria, Roberts and others have described cases 
in which the urine contained bacteria at the time of being voided. He 
makes four groups : (1) Cases in which the presence of bacteria is asso- 
ciated with incipient putrefactive changes in the urine ; (2) cases associ- 
ated with ammoniacal fermentation of the urine ; (3) cases in which 
common forms of bacteria are present without decomposition of the 



PLATE XLVIII. 




J? ' # 



Uric Acid. 

A. Common forms. B. Amorphous urates. 
(Ob. D. and A.. Oc. 4.) Drawn by J. D. Z. Chase. 



FIO. 2. 



<f 



w 



45 



r- 




#V^ 



Combination of Uric Acid and Calcium Oxalate. 

(Oc. 4, Ob. D.) Drawn by J. D. Z. Chase. 



DISEASES OF THE KIDNEYS. 949 

urine ; and (4) cases in which micrococcus-chains are voided in the 
urine. 

The pathogenic organisms which are more or less closely associated 
with infectious diseases, septic processes, and tuberculosis are found 
at times in the urine, and can be demonstrated by the proper staining- 
methods. 

Fig. 216. 
-" £ 

\ Vy 

Vibriones in urine. (Roberts.) 

Dock has given an admirable account of the occurrence of the tri- 
chomonas in the genito-urinary passages. This parasite belongs to the 
flagellate infusoria. The prominent symptoms caused in Dock's case 
were painful, difficult, and frequent urination, followed by hsematuria. 
The urine contained pus, epithelium of all kinds, and a number of bodies 
slightly larger than pus-corpuscles of a peculiar amyloid appearance — 
the trichomouades. 

Morbid Growths. The urine very rarely contains the elements of 
morbid growths. Von Jaksch says he never has found them in any 
way reliable in the case of tumors of the kidney. The detection of 
cancer-cells or pigmented cells, such as occur in melanotic cancers, 
may confirm the diagnosis if the clinical symptoms point to cancer. 
Tumor-elements are most likely to be found in ulcerating tumor of the 
bladder. 

Unorganized Sediments. Uric Acid. Uric acid is present in small 
quantities (eight to ten grains a day) in normal urine. It is increased 
in febrile and wasting diseases, such as phthisis ; in diseases of the 
liver and spleen (leukaemia), and in malarial fever, diabetes, scurvy, 
rhachitis, and following an attack of gout. Excessive use of milk is 
said to increase it. Its excretion is also increased by certain drugs — 
colchicum, corrosive sublimate, salicylic acid, and euonymin. 

It is diminished in anaemia, chlorosis, and during a paroxysm of gout ; 
in chronic nephritis ; by certain drugs — large doses of quinine (Ranke), 
caffein, sodium chloride and sodium carbonate, lithia, and iodide of 
potash. (Plate XLYIIL, Figs. 1 and 2.) 

According to Roberts, a deposit of uric acid occurring some twelve 
to twenty-four hours after the urine has been passed has no patholog- 
ical significance. If the deposit occurs within three or four hours after 
the urine has been passed, it is certainly not natural. It is frequently 
observed in convalescence from febrile complaints, especially articular 
rheumatism ; also in the middle periods of chronic Bright' s disease, in 
chorea, in certain types of diabetes, and in enlargement of the spleen. 
If, however, the uric acid is precipitated before the urine cools, or im- 
mediately afterward, it is probable that the same precipitation may occur 
within some part of the urinary passages, and so form a calculus. 



950 



SPECIAL DIAGNOSIS. 



Urates. Amorphous urates appear under the microscope as opaque 
granular particles, which dissolve upon heating, and respond to the 
murexid test. The deposit is more or less dense, and is sometimes 
arranged so as to resemble granular casts. 

Fig. 217. 





Sodium urate. 

a a. From a gouty concretion, b b. Arti- 
ficially prepared by adding liq. sodse to the 
amorphous urate deposit. (Roberts.) 



Ammonium urate spontaneously 
deposited. 
a. Spheres and globular masses, b. 
Dumb-bells, crosses, rosettes. (Rob- 
erts.) 



Sodium urate appears as spherules or globules, from which project 
short spines, either straight or curved. It occurs most frequently in 
concentrated acid urines, such as are passed by children with acute 
febrile diseases. (Fig. 217.) 



Fig. 218. 




Ammonium urate. 



AMMONIUM URATE resembles sodium urate. It is frequently asso- 
cm\<-(\ with phosphatic deposits, and is precipitated from alkaline 
mines. Sometimes it appears in the shape of dumb-bells. (Figs. 217 
and 218.) _ ^ 

Phosphates. Phosphates appear in the urine as ammonio-magne- 
sium phosphate and as the crystalline and amorphous phosphate of lime. 



DISEASES OF THE KIDNEYS. 



951 



They are precipitated in alkaline or faintly acid urines, which produce 
a cloud upon being heated ; the cloud is distinguished from albumin, 
as already pointed out, by the fact that it disappears when the urine is 



Fig. 219. 







Triple phosphates. 



acidulated with acetic or nitric acid. Ammonio-magnesium phosphate 
is easily recognized by its rhombic prisms — " coffin-lid " shape. Other 
shapes are ^produced by modification of the primary one, chiefly by 
bevelling of the edges and hollowing out of the sides. These crystals 



Fig. 220. 




Calcium phosphate crystals. 



are usually large, and are frequently found, together with amorphous 
phosphates, bladder epithelium, and pus, in cases of cystitis. 

Amorphous phosphate of lime consists of fine granular particles much 
resembling amorphous urates, but distinguished from them by not dis- 



952 SPECIAL DIAGNOSIS. 

appearing upon the application of heat, but instantly dissolving when 
the urine is acidulated. 

Crystalline phosphate of lime is a not infrequent deposit. It is 
found as narrow-wedged crystals, occasionally grouped together in the 
form of stars, sheaves, or bundles, with their apices at a common 
centre. 

According to Roberts, this deposit, in quantity, is an accompaniment 
of some grave disorder. He has found the stellar phosphates in cancer 
of the pylorus, once in phthisis, and more than once in patients ex- 
hausted by obstinate rheumatism. It may, however, occur in health, 
when the urine is rich in lime and its acidity greatly reduced. 

In one or two cases of renal colic the writer has observed numerous 
shining particles, which, upon microscopical examination, have been 
shown to be an opalescent film, covered with small, sharp phosphatic 
(probably calcium) crystals. (Fig. 221.) 

Fig. 221. 




Opalescent film in a case of renal colic. 

Oxalate of Lime. Oxalate of lime occurs in the form of small octa- 
hedral crystals, or, more rarely, as dumb-bells, and in the form of ovals 
or disks. It is precipitated almost always from acid urines. (Plate 
VI., Fig. 2 ; and Fig. 222.) 

Oxaluria. According to Beneke, oxaluria has its proximate cause in 
an impeded metamorphosis, an insufficient activity of that stage which 
changes oxalic acid into carbonic acid. 

When oxalates are constantly found in the urine a condition of pro- 
found hypochondriasis is found to exist, but it has no necessary relation 
to the oxaluria. An increase of oxalates in the urine is found in dia- 
betes, especially when there is diminution in the amount of sugar. It 
is in excess in certain forms of indigestion. Its constant passage may 
be attended by pains in the back and loins. Flatulent and nervous 
dyspepsia usually accompany the increase, and neurasthenia also may 
be present. 



DISEASES OF THE KIDNEYS. 



953 



Cystin. Cystin occurs in the form of hexagonal prisms, either as 
irregular masses or superimposed one upon another, so as to form 
truncated pyramids. It is a very rare sediment, but appears to be 
most common in children and young male adults. Several members 
of the same family have been known to pass it. Its chief clinical sig- 
nificance arises from the fact that rarely it is the basis of calculi. 

Fig. 222 . 







Calcium oxalate. 



Leucin and Tyrosin. Leucin and tyrosin are generally described 
together, though the former is not spontaneously deposited from urine. 
It appears in the form of spheres, which refract light strongly and have 
a radiating arrangement. (Fig- 223.) 



Fig. 223. 




Crystals of leucin (different forms). (Crystals of creatinin chloride of zinc resemble the leucin 
crystals depicted at a.) The crystals figured toward the right consist of comparatively impure 
leucin. (From Charles : Chemistry.) 

Tyrosin has been found as a sediment, of a light greenish-yellow color, 
in typhoid fever and acute yellow atrophy of the liver. It appears in 
the form of tolerably long, needle-like crystals, or as bundles and 
sheaves. Frerichs attaches great importance to leucin and tyrosin in 
the diagnosis of acute yellow atrophy of the liver. (Fig. 224.) 



954 



SPECIAL DIAGNOSIS. 



Cholesterin. This occurs at times in fatty degeneration of the kid- 
neys, jaundice, chyluria, diabetes, and, according to Pohl, in the urine of 
epileptics treated with bromide of potash. (Fig. 225.) 



Fig. 224. 




Tyrosin crystals. 

Melanuria. Melanin is held in solution or suspended in small gran- 
ules. The urine is dark in color, and blackens intensely when sulphuric 
acid or tincture of chloride of iron is added to it. A concentrated solu- 
tion of perchloride of iron serves to detect the presence of the substance. 



Fig. 225. 




Crystals of cholesterin. 



A few drops added to the urine turn it gray. If a few drops more are 
added, the phosphates are precipitated along with the coloring-matter. 
Both are dissolved by an excess of the iron solution. Melanin is usually 
found in cases of melanotic carcinoma. 



DISEASES OF THE KIDNEYS. 955 

Catheterization and Exploration of the Ureters. 

Examination of the bladder, the ureters, and the pelvis of the kidney 
has been wonderfully advanced by the genius of Howard Kelly. The 
following instruments are required for the examination of the bladder : 
Female catheter ; urethral calibrator ; a series of urethral dilators ; a 
series of specula with obturators ; common head-mirror and a lamp, 
Argand burner or electric light ; long, delicate mouse-toothed forceps ; 
suction-apparatus for completely emptying the bladder ; ureteral 
searcher ; ureteral catheter with a handle ; small bran-bags for ele- 
vating the pelvis. 

The procedure is as follows : Empty the bladder ; measure the meatus 
urinarius externus ; dilate the urethra to twelve or fifteen millimetres ; 
insert speculum of diameter of last dilator and remove obturator ; 
elevate the hips of the patient about a foot above the level of the 
table; inspect with light; remove residual urine by suction or with 
cotton and mouse-toothed forceps. 

For anaesthesia, a pledget of cotton saturated with a 5 per cent, solu- 
tion of cocaine may be introduced seven minutes before dilatation. On 
removal of the obturator the bladder becomes distended with air. The 
bladder is viewed by turning the speculum, and each ureteral orifice is 
brought into view by turning the speculum thirty degrees to one side 
or the other. Kelly says : " The orifice appears as a dimple or a little 
pit, or, in inflammatory cases, as a round hole in a cushioned eminence ; 
at other times as a ^ with the point directed outward ; again, it may 
be scarcely visible even to a trained eye, appearing as a fine crack in 
the mucosa, and occasionally is so obscure as to be recognized only by 
the jet of urine as it escapes, or by a slight difference in the color of 
the mucous membrane at that point. In rare cases it has the form of 
a truncated cone with gently sloping sides ; this appearance is most apt 
to be developed in the knee-breast position. The bladder mucosa is 
usually of a slightly deeper rose color around the ureter, and in the 
presence of an inflammatory process it even appears deeply injected.'' 

Catheterization of the Ureters. The catheters are sterilized ; they are 
stiffened with a wire stylet. The orifice is exposed, and then the outer 
end of the catheter being held over the shoulder by an assistant, the 
conical end is introduced and pushed up the ureter, while at the same 
time the stylet is being removed. The speculum is removed and again 
introduced beside the first catheter. The remaining ureter is then cath- 
eterized ; both are properly designated and allowed to drain into test- 
tubes plugged with sterilized cotton and fixed in a block of wood. By 
catheterization, aspiration, and exploration of the ureters with a bougie, 
the source of pysemia anywhere from the urethral orifice to the renal 
pelvis can be found ; renal calculi diagnosticated ; strictures of the 
ureter located ; hydronephrosis distinguished from soft malignant 
growths ; and the functional value of each kidney determined. 

Kelly suggests the following guide to the ureteral orifice : "A. point 
is marked on the cystoscope 5 J cm. from the vesical end, and from this 
point two diverging lines are drawn toward the handle with an angle 
of sixty degrees between them. The speculum is introduced up to the 



956 SPECIAL DIAGNOSIS. 

point of the V, and turned to the right or left until one side of the 
Y is in line with the axis of the body ; then by elevating the endo- 
scope until it touches the floor of the bladder the ureteral orifice will 
usually be found within the area covered by the orifice of the speculum." 
By means of a searcher, or sound, the suspected orifice is further ex- 
amined. 

Objective Symptoms due to Impairment of the Function 
of the Kidney. 

Uraemia. Under symptoms due to impairment of the functions of 
the kidney belong the various manifestations of ursemia. Diseased 
kidneys do not eliminate the products of tissue-waste, which are poison- 
ous materials. The toxic matter is retained within the blood, and 
produces toxaemia, which may be acute or chronic. In acute urcemia 
the manifestations develop suddenly and continue but a short period 
of time, with alarmingly active symptoms until death or recovery. In 
chronic urcemia the onset is gradual. The manifestations may be lim- 
ited to one or two conditions, as headache or morning nausea, or they 
may include the more pronounced symptoms of ursemia. 

Nervous Symptoms. 1. Headache. The pain is situated in the 
occipital region, and may extend down the neck. It is severe and of 
a bursting character. It may be associated with giddiness. In both 
acute and chronic nephritis it is often the first manifestation. It may 
be associated with eye-symptoms. It may be present on waking, and 
continue only through the morning hours. In acute ursemia it persists 
throughout the attack. Numbness and tingling of the fingers are often 
complained of at the same time. 

2. Delirium. The delirium may be mild. This is usually the case 
in the typhoid state or if a subnormal temperature prevails. It is 
sometimes attended by delusions. There is often subsultus, and pick- 
ing at the bedclothing. The delirium may amount to true mania, and 
the patient may exhibit other maniacal symptoms. On the other 
hand, the patient may be noisy, restless, and sleepless. Melancholia 
and delusional insanity may develop after the violent nervous symptoms 
of ursemia pass off. 

3. Convulsions. A convulsion may be the first indication of disease 
of the kidneys, or it may succeed a few days of persistent headache, 
or follow an attack of ursemic vomiting. The convulsion resembles 
epilepsy, and hence is known as an epileptiform convulsion. If the 
spasms recur in rapid succession, the interval is occupied by delirium 
or coma. If they are infrequent, the patient's mind may be clear in 
the intervals. Sometimes a focal or Jacksonian epilepsy occurs instead 
of the true epileptiform convulsion. The temperature is usually elevated. 
In worn-out subjects, or those who have had exhaustive diarrhoea, or 
are debilitated from other causes, the temperature may be subnormal. 
A temporary blindness often follows the convulsion (urcemic amaurosis). 
Uraemic deafness may occur. 

4. Coma. After the convulsion the mind may be restored, or the 
patient may lapse into stupor, followed by complete coma. Coma may 



DISEASES OF THE KIDNEYS. 957 

develop without convulsions, or immediately succeed a general convul- 
sion. Headache or eye-symptoms may precede the coma. In some 
instances the patient lapses into a typhoid state, in which the tongue is 
heavily furred and the breath very offensive. Unless the coma is pro- 
found there is usually some twitching of the muscles of the hands and 
face. 

5. Local palsies. Dercum was among the first to call attention to the 
occurrence of uraeniic monoplegia or hemiplegia. The cases resemble 
central cerebral disease. The nature of the palsy is inferred from the 
results of the examination of the urine and the condition of the heart 
and arteries. Palsy develops suddenly, or may occur after a convul- 
sion. 

6. Cramps in the muscles of the calves, particularly at night, are of 
common occurrence, and should always lead to an examination of the 
urine. 

7. Pruritus, local or general, is another nervous symptom which may 
be of uraemic origin. 

8. Pain in the upper abdomen, particularly in the median line, is a 
frequent precursor of more severe uraemic symptoms. It is of uraemic 
origin itself. It may be seated in either of the upper quadrants, and 
thence extend to the lower portion of the abdomen. 

Uremic Dyspncea. Modifications of the breathing often accom- 
pany symptoms of uraemia. The dyspnoea may be constant. It may 
occur in paroxysms, or both types may alternate. A common type in 
the uraemia of chronic nephritis is the Cheyne-Stokes breathing. 
Paroxysmal dyspnoea usually occurs at night, and resembles asthma 
in every respect. Cheyne-Stokes breathing continues, even through 
the period of coma, although not necessarily associated with it. (See 
page 456.) 

In addition to uraeruic dyspnoea, the occurrence of inflammatory 
pulmonary complications may be the first indication that the condition 
of the urine should be inquired into. Bronchitis, pneumonia, and 
pleurisy are common complications. 

Gastrointestinal Symptoms of Ujrjemia. Several forms are 
seen. 1. Loss of appetite is common. It is attended with absolute 
distaste for food after a small portion is taken. 2. Nausea, which 
may be continuous, or more frequently limited to the early morning. 
3. Vomiting may be paroxysmal, occurring chiefly in the early morn- 
ing, or it may be sudden in onset, uncontrollable, and continue until 
nervous symptoms of uraemia develop. Urea is found in the vomit. 
The matter ejected is profuse, of a low specific gravity, and at first 
acid in reaction. If chronic, it may become alkaline. The odor is 
often sufficient to cause its recognition. 4. Constipation is generally 
the rule in the course of chronic Bright' s disease. 5. Diarrhoea. One 
of the manifestations of uraemia is the occurrence of sudden, profuse 
serous purging. This may be so extreme as to cause collapse, or may 
usher in coma and convulsions. 6. Hiccough, although a muscular 
affection, is usually associated with gastric disturbances. 

Latent uraemia was first recognized by Sir William Roberts. It is 
seen in its most characteristic form in calculus suppression. The 



958 SPECIAL DIAGNOSIS. 

patient for several days will have subnormal temperature, myosis, 
occasional vomiting, and toward the end twitching of the voluntary 
muscles and slight drowsiness. After the end of five or ten days 
coma, convulsions, or dyspnoea ensue. 

Cardiovascular Symptoms of Nephritis. The symptoms are 
the effects of the retention of morbid products. First, the heart and 
bloodvessels. The poison which is not excreted circulates throughout 
the system. One of its effects is irritation of the vasomotor nerves of 
the bloodvessels. Excitation of these nerves causes peripheral con- 
traction of the smaller vessels. At once the flow of blood is obstructed, 
so that, on account of the contraction, hypertrophy of the heart rapidly 
ensues. The first prominent symptom, therefore, is due to changes in 
the heart-muscle. 

Hypertrophy of the Heart. The most pronounced change is hyper- 
trophy. The persistent spasm of the peripheral vessels causes in- 
creased arterial tension. The blood-pressure is raised and causes 
increased accentuation of the aortic second sound. High tension in 
the artery is recognized by the peculiar character of the pulse and by 
means of the sphygmograph. 

Dilatation of the Heart. Unfortunately, hypertrophy of the heart 
cannot always be kept up. If it fails, we then have a second con- 
dition of the heart which is frequently found in renal inflamma- 
tions ; it is dilatation. The state of the coronary arteries predisposes 
to this condition of the heart-muscle. The previously mentioned 
arterial tension favors the development of chronic endarteritis with 
general atheroma. The coronary arteries take part in this process. 
The endarteritis hinders cardiac nutrition, dilatation of the heart- 
muscle follows, and later comes the development of two other condi- 
tions, atrophy and myocarditis. 

Here may be mentioned other relations of the heart and kidneys : 
a. TTe have renal disease following forms of cardiac disease. In dila- 
tation of the heart passive congestion of the particular organ takes 
place. The kidney very quickly becomes the seat of such congestion. 
In the course of simple dilatation, or of valvular heart-disease, the 
secondary dilatation, passive congestion, and chronic inflammation 
develop slowly. Embolism may also occur, b. Renal disease and 
cardiac disease may develop at the same time from a common cause, 
as alcoholism, gout, or endarteritis. 

In addition to high arterial tension and accentuation of the aortic 
second sound, the objective symptoms of atheroma of the aorta and 
arteries are present with the chronic inflammations of the kidney. 
These vascular changes need not be again rehearsed. (See Endarteritis.) 

It is important, however, to bear in mind that they frequently occur 
together, and also that in all instances of arterial disease the condition 
of the urine must be inquired into. It need not be said that symptoms 
• I in- to rupture of the bloodvessels, particularly in the brain, or to an- 
eurism, necessarily may be present in the course of renal inflammation. 

Gastrointestinal Symptoms. Fermentative dyspepsia, gastralgia, 
chronic gastritis, enteritis, and ulcerative colitis are of common occur- 
rence. 



DISEASES OF THE KIDNEYS. 959 

Hemorrhages. The arteries are very liable to rupture, causing 
epistaxis, retinal hemorrhage, hemorrhages from the bowels and lungs, 
and hemorrhages underneath the skin. Frequent hemorrhages in large 
amounts from any portion of the body should call attention to the 
condition of the urine. 

Ophthalmoscopic Changes. The eye-ground should always be 
examined ; indeed, the patient himself by his complaints often directs 
attention only to the eye, the examination of which discloses the pres- 
ence of an albuminuric retinitis. The changes may occur in the acute 
or chronic forms of nephritis, although they are more common in the 
latter. 1. A diffuse, slight opacity and swelling of the retina, due to 
oedema. 2. White spots or patches of various sizes, for the most part the 
result of degenerative processes. 3. Hemorrhages. 4. Inflammation 
of the intraocular end of the optic nerve. 5. Atrophy of the retina and 
nerve may sometimes result from and succeed the inflammatory changes. 
These changes may affect one eye only (Gowers). It must not be for- 
gotten that temporary blindness may occur independently of retinitis. 

Dropsy. Dropsy may occur in all forms of nephritis. It is most 
common in acute varieties, but it is also present in chronic diffuse neph- 
ritis with exudation. Renal dropsy usually begins in the face. It may 
develop suddenly in acute forms. In the marked forms, oedema of the 
eyelids may continue for a long time. All varieties may be found, from 
local oedema to extreme anasarca. The serous cavities are also filled. 
The oedema is usually associated with a diminished amount of urine. 
Its improvement is attended by increased diuresis. Dropsy, in chronic 
disease, is usually due to dilatation of the heart. (See page 100). 

The Cutaneous Symptoms, and Appearance of the Face. 
In mflammatory affections of the kidney, the appearance of the skin 
and expression of the face are often characteristic, and point at once to 
an examination of the urine. The face is pallid, and of an ivory white- 
ness. In the chronic form the pallor gives way to an ashen-gray or 
sallow complexion. In chronic nephritis the skin becomes dry and 
harsh, and, rarely, is covered with a powdery substance, giving it the 
appearance of frost on the skin. The powdery substance is due to urea. 

Petechke. In the later stages of chronic inflammatory affections 
hemorrhages under the skin and in the mucous membrane are seen. 

Anaemia. Anaemia is a frequent symptom in all forms of nephritis ; 
it is usually marked. It is associated with the peculiar pallor just 
described, and attended by all the other usual symptoms. 

General Symptoms. The cause of renal disease, as far as symp- 
toms pointing to the kidneys are concerned, is often latent. Instead 
of renal symptoms, a generally depraved state of the system may be 
seen, with emaciation and weakness. Lassitude without cause demands 
an examination of the urine. 

Diabetic Coma. Acetonsemia is a toxaemia which develops in the 
terminal stages of diabetes. It is due to an accumulation of acetone 
in the blood. It is also called diabetic coma. It develops acutely. A 
sudden onset is attended by sharp pain in the stomach with nausea, and 
frequently vomiting. At the same time there is severe dyspnoea. The 
breathing is irregular and of a panting character, with inspiratory and 



960 SPECIAL DIAGNOSIS. 

expiratory dyspnoea. There may or may not be cyanosis. The patient 
is obliged to sit up in bed on account of the air-hunger. Restlessness 
begins at once. Delirium develops within the first hour. In a few 
hours coma sets in. The temperature is subnormal ; the pulse is irreg- 
ular, and soon becomes weak and thready. The odor of acetone is 
detected on the breath. 

Congestion of the Kidney. 

Congestions of the kidney are acute and chronic, and depend upon 
changes in the circulation, whereby blood accumulates in the kidney. 

Acute congestion of the kidney is caused by the action of irritant 
poisons ; it follows surgical operations, particularly if prolonged, and 
may follow extirpation of one kidney. Diseased kidneys are apt to 
become the seat of active congestion. 

Symptoms. The urine is diminished in amount, or may be suppressed 
entirely. Only a small amount is passed at frequent intervals, or it can 
be secured by the catheter alone. Albumin is present in considerable 
amount, and blood and epithelial casts are numerous. Death may take 
place, with symptoms of urseinia. 

Chronic Congestion of the Kidney. It is also called passive conges- 
tion. This form of congestion is usually a part of general venous stasis, 
due to disease of the heart or lungs, as valvular disease of the heart, 
with secondary dilatation or pulmonary emphysema. It is quite com- 
mon. 

Symptoms. The urine is diminished in amount ; dark in color ; of 
high specific gravity, ranging from 1020 to 1030. Uric acid and 
urates are increased. Urea to the amount of from 10 to 12 grains to 
the ounce is passed in twenty-four hours. At first there is no further 
change, but, subsequently, albumin appears in small amounts in an 
intermittent manner. Later, it is constant and increased in amount. 
Hyaline casts are found in the urine, and a few red blood-cells. 

The condition is recognized by its association with congestion in other 
organs ; by the diminution in the amount of urine, its high specific 
gravity, and excess of uric acid and urates. This form of congestion 
is serious, because it leads to chronic nephritis. The latter is recog- 
nized by the usual changes in the urine. 

Inflammations of the Kidney. 

The inflammations of the kidney are divided in accordance with the 
activity of the process and the degree of exudation or cell-proliferation 
that attends the inflammation. We, therefore, have the following 
varieties : 

Acute exudative nephritis (acute Bright's disease). 

Acute productive or diffuse nephritis (acute Bright's disease). 

Chronic productive or diffuse nephritis with exudation (chronic 
tubular nephritis). 

Chronic productive or diffuse nephritis without exudation (chronic 
i 1 1 1 < rstitial nephritis). 

Suppurative nephritis. 






DISEASES OF THE KIDNEYS. 961 

Tubercular nephritis. 

Acute Exudative Nephritis or Glomerulonephritis. In 
this form of nephritis there are congestion, exudation of plasma, trans- 
udation of red and white blood-cells, and changes in the epithelium. 

Causes. It may occur without definite cause, save exposure to cold, 
and at times even without such history. It occurs in most of the infec- 
tious diseases. It is of common occurrence after scarlet fever, and in 
the course of pregnancy and in septicaemia. It occurs in diphtheria, 
erysipelas, and pneumonia frequently. It is the expression of a pecu- 
liar type of typhoid fever. It may complicate dysentery and acute 
tuberculosis. It forms one of the modes of termination of diabetes. 

Symptoms. The course of the disease may be mild, presenting only 
changes in the urine, or there may be, in addition to decided changes 
in the character of the urine, local and general symptoms. 

In mild cases the urine is diminished in amount ; micturition is fre- 
quent ; the color of the urine is increased, and the specific gravity is 
usually high. A small amount of albumin is found, and a few epithe- 
lial and blood-casts, and sometimes blood. At the termination of the 
disease the casts are hyaline. 

In severe cases the disease is ushered in by chill, attended and fol- 
lowed by pain in the loins, with, fever, headache, and much restlessness. 

The urine may be passed more frequently than usual, but in small 
amounts ; or micturition may diminish in frequency or cease entirely. 
Examination of the urine reveals the characteristic changes. The 
quantity of the urine is lessened ; the specific gravity is normal or 
increased. There is a large amount of albumin, and an abundance 
of hyaline, granular, epithelial, and blood-casts. Free white and red 
blood-cells, and epithelium from the pelvis and tubules are found. 

The fever continues ; the pain in the loins is sometimes very severe, 
and may be taken for lumbago, unless an examination of the urine is 
made. Within the first forty-eight hours the characteristic symptoms 
that follow the chill and that attend the urinary changes are headache, 
sleeplessness, more or less stupor, muscular twitchings, or general convul- 
sions. Eye-symptoms may be present. Instead of cerebral symptoms, 
dyspnoea may be marked. With both, nausea and vomiting are of 
common occurrence. The heart's action is increased in force and fre- 
quency. The left ventricle rapidly becomes hypertrophiecl. The aortic 
second sound is accentuated. The pulse is hard and exhibits the char- 
acteristic features of high tension. From the onset of the first symptom, 
or within the first week, two other striking phenomena arise. They are, 
first, the occurrence of dropsy ; second, the occurrence of ancemia. 

Dropsy or oedema is one of the most constant symptoms. It appears 
first in the face, especially the eyelids. It may be limited to this region. 
It is worse in the morning. From the face, in bad cases, it extends to 
the lower extremities and to the scrotum, and thence all over the body. 
Anasarca is the name applied to the general dropsy ; the connective 
tissue is infiltrated with serum. It is recognized by the pallor of the 
swollen surface ; the pitting on pressure ; the absence of heat and of 
pain. (See page 148.) 

Effusion may take place into the serous cavities, either the pleura, 

61 



962 SPECIAL DIAGNOSIS. 

pericardium, or peritoneum, causing the symptoms due to effusion- 
In some instances there is oedema of the mucous membranes, as the 
conjunctiva, the soft palate, and the glottis. 

Dyspnoea may be a pronounced symptom, due either to uraemia 
(ursemic asthma) or oedema of the glottis, effusions into the pleura, or 
to bronchitis. If dilatation of the heart occurs, dyspnoea may arise, 
due to that or to the secondary' oedema of the lungs. 

With or without the occurrence of nausea or vomiting there is always 
loss of appetite, and usually constipation. 

The fever is usually moderate and irregular in type. Prostration is 
common ; often there is emaciation. Symptoms of xiramiia may occur 
at any time. 

Exudative nephritis with excessive pus formation is of sudden onset, 
characterized by high fever and extreme prostration. There is rapid 
emaciation and the early development of the typhoid state. This is 
preceded by delirium, headache, and stupor, with great restlessness. 
There is but little, if any, dropsy. Large numbers of red and white 
blood-cells and the usual casts are found in the urine. There is not so 
much diminution in the urine as is usually seen. The disease may 
arise without apparent cause, or complicate scarlet fever or diphtheria. 

This form is very fatal, and resembles acute meningitis, from which 
it is diagnosticated by the change in the urine. 

Acute Productive or Diffuse Nephritis. In this form there 
is an overgrowth of connective tissue, and excessive growth of the 
capsule-cells in the glomeruli, in addition to the lesions of the first 
form. The whole kidney is not necessarily affected, but only portions 
at a time. Symptoms : The onset is sudden. The subjective symptoms 
previously described are present in a marked degree. Nervous symp- 
toms (uraemia) are most pronounced. Dropsy develops rapidly and to 
an extreme degree. There is rapid development of anaemia and loss of 
flesh. The remaining symptoms tally with those of the first affection. 

The urine is scanty, bloody, and of high specific gravity. The micro- 
scopical appearances are like those of acute exudative nephritis. If 
convalescence is established, the urine becomes more abundant, with a 
corresponding fall in the specific gravity. The albumin and casts may 
appear for a time, but eventually disappear. 

Diagnosis. The diagnosis of acute nephritis of either form is based 
upon the examination of the urine. Etiological associations are of 
value. The more pronounced cases follow scarlet fever and pregnancy. 

In the latter condition it usually advances slowly. There may be 
no symptoms until the occurrence of uraemia. In some instances the 
disease resembles typhoid fever. In cases in which the onset is sud- 
den, with early uraemic symptoms, it must not be mistaken for epilepsy, 
delirium, or mania. 

Chronic Productive or Diffuse Nephritis with Exudation. 
In chronic inflammations the formation of new tissue always takes 
place. They are divided, therefore, into exudative and non-exudative 
inflammations. The exudation is from the vessels. Causes : This form 
usually follows acute productive nephritis and chronic congestions or 
degenerations of the kidney. It develops in the course of syphilis, 



DISEASES OF THE KIDNEYS. 963 

tuberculosis, endocarditis, disease of the bones, and prolonged suppura- 
tion. Frequent exposure to cold and wet, a residence in damp dwell- 
ings, and the alcoholic habit are causal conditions. It usually occurs 
in middle life, more frequently in men. When it occurs as a primary 
disease it is usually found in young adults. Symptoms : The disease 
develops slowly. General symptoms may first be observed. Dropsy 
may develop at first and continue throughout the disease, or recur at 
long intervals. The appearance of the patient is striking. The skin 
is of a peculiar pallor and is pasty in appearance. The sclerotics are 
very white. The anaemia which gives rise to the pallor is profound, 
and often closely resembles that of pernicious anaemia. The anaemia 
is due to diminution in the haemoglobin and reduction in the number 
of red blood-cells. 

Headache and sleeplessness are common symptoms. Pronounced acute 
uraemia does not often occur. Chronic urcemia may prove fatal by the 
patient lapsing into a typhoid state, in which delirium alternates with 
stupor. 

The urine is variable in quantity and character. It must not be for- 
gotten that the course of the disease and the urinary symptoms are often 
quite variable in chronic nephritis. The urine may be normal in amount, 
but during the exacerbations it is scanty or suppressed. The specific 
gravity and the amount of urea lessen. In the most rapid cases it 
varies between 1012 and 1020. In chronic cases it falls as low as 1005 
and even 1001. In the later stages the amount of the urine and the 
specific gravity may both be increased. Albumin is present in large 
amounts. When the disease is most active, and the dropsy at its 
height, the quantity of albumin is very large. In the quiescent period 
of the disease the amount is lessened. Casts are abundant, both epithe- 
lial, fatty, and granular ; red blood-cells are often found. 

Retinitis albuminuria is frequently developed in the course of the 
disease. 

Dyspnoea is a common symptom. The dyspnoea may be due to any 
one of the many causes previously described which produce this symp- 
tom in the course of nephritis. It is frequently limited to sudden 
attacks which develop in the night or early morning. There is often 
some bronchial catarrh. 

Nausea and vomiting are common symptoms. The appetite is lost. 

Hypertrophy of the left ventricle takes place in all cases, except in 
those who had been previously weakened by other disease. The right 
ventricle is often hypertrophied also. The second aortic sound is 
accentuated, and the pulse is of high tension. Symptoms, such as 
headache and vertigo, arise on account of the profound anaemia. 

The disease is characterized in its course by remissions and exacerba- 
tions. During the exacerbations any one of the prominent symptoms 
that occur in renal inflammations may be present. (Edema is the one 
symptom which occurs most frequently, and is likely to continue the 
longest. The disease lasts from three months to three years, and may 
pass into the second variety of chronic inflammation. 

Course of the Disease. Delafield has well outlined the course. The 
constant symptoms are anaemia, dropsy, and albuminuria. 1. The 



964 SPECIAL DIAGNOSIS. 

symptoms may be continuous and progressive in severity, death taking 
place at the end of one or two years, on account of dropsy or uraemia. 
2. The symptoms may continue for several months, and the patient 
finally improve. Recurrent attacks take place, the symptoms being 
more severe with each attack. In the intervals of the attacks there is 
a small amount of albumin in the urine. 3. The patient may appar- 
ently recover, but the urine continues to be of low specific gravity, and 
contains some albumin. A fatal attack of uraemia, or an apoplexy, or 
the onset of an acute disease may cause an exacerbation of the renal 
symptoms. 4. The symptoms may persist in a mild degree for years, 
the patient at the same time feeling comparatively well. 5. Spasmodic 
dyspnoea may be the first and only symptom for a long time. 

Chroxic Productive or Diffuse Nephritis without Exuda- 
tion. This is the form of nephritis which is also called interstitial 
nephritis, granular kidney, or cirrhosis of the kidney. 

The kidneys are diminished in size, the capsules are adherent, and 
the surface roughened. There is an overgrowth of connective tissue 
with atrophy of the epithelium and of the tubules, and dilatation of 
some of the tubes, forming cysts. 

Causes. This form of nephritis follows chronic congestion of the 
kidney, and is also caused by alcohol, lead, gout, syphilis, malaria, and 
by chronic endarteritis. The latter condition, as well as cirrhosis of 
the liver and pulmonary emphysema, frequently develops hand-in-hand 
with the nephritis. This form of nephritis is notably prevalent in 
several generations of different families, so that an hereditary history 
is often readily obtained. 

Symptoms. The onset of the disease usually occurs late in life, 
although well-defined cases may occur as early as the twenty-fifth 
year. The progress at first is very insidious, and the disease may have 
advanced to an extreme stage without the occurrence of a single symp- 
tom. Death, indeed, may be due to other causes ; or a person in 
apparently perfect health may suddenly manifest symptoms of uraemia, 
or may develop apoplexy or some other usual accompaniment of inter- 
stitial nephritis. 

The urine is increased in amount, clear in color, and of low specific 
gravity. The albumin is small in amount, or may be absent. Repeated 
examinations extending over a considerable period of time may dis- 
close its presence. Hyaline casts are present in small numbers. In 
some cases it may be necessary to examine a dozen or fifteen slides 
before they are found. Sometimes there are a few red blood-cells. 
Rarely the urine is bloody at irregular periods in the course of the 
disease, or actual hematuria may take place. With the exception of 
the state of the urine, the only symptom present may be the loss of 
flesh and strength. At the same time the skin becomes dry and harsh. 
CEdema, however, is not usually present unless there is dilatation of 
the heart. Special symptoms are due to uraemia, to changes in the 
heart and arteries, and to neuroretinitis. 

The Heart. The left ventricle hypertrophies. The aortic second 
sound is accentuated. The pulse is of high tension. The arteries 
become more prominent, and present all the signs of endarteritis. In 



DISEASES OF THE KIDNEYS. 965 

the later stages, as nutrition fails, dilatation of the heart takes place, 
with regurgitation at the mitral valve, and the development of a train 
of symptoms due to these changes. Among others we find general 
malaise, palpitation of the heart, dyspnoea, oedema, and visceral conges- 
tions. 

Urcemie Symptoms. These symptoms may occur at any time in the 
course of the disease. Headache is most common and constant. It 
may occur early in the morning only, or continue throughout the day. 
It may be continuous and cause sleeplessness. General neuralgic pains 
may be present instead of severe headache. Muscular twitchings or 
general convulsions may be other pronounced symptoms, or, instead, 
delirium, mild or violent, stupor, and coma may come on. These 
symptoms occur suddenly or develop very gradually. In acute uraemia 
with the above-mentioned cerebral symptoms there is peripheral spasm 
of the arteries, causing high arterial tension, and there is elevation of 
the temperature. The fever may rise to 103° or 104°, but is usually 
about 102°, and is irregularly continuous. After the patient lapses 
into deep coma, if the attack is fatal, the tension of the pulse is lost, 
and it is increased in frequency and diminished in strength. In chronic 
uraemia the cerebral symptoms develop gradually. The temperature is 
likely to be subnormal, particularly if diarrhoea or other debilitating 
influence is coincident. The pulse is rapid and feeble. 

Pulmonary symptoms due to uraemia are quite common. They may 
be the first expression of uraemia. This is seen in all forms of nephritis. 
The most marked symptom is dyspnoea, which is spasmodic and of 
short duration. The attacks may occur frequently, and are usually 
increased by exertion and aggravated by a recumbent posture. The 
shortness of breath may occur in the early morning hours, or may con- 
tinue throughout the clay. 

Pulmonary symptoms, other than those of uraemia, may be due to an 
intercurrent bronchitis, pneumonia, or pleurisy. Chronic bronchitis or 
oedema of the lungs may be present, on account of dilatation of the right 
heart. The chief pulmonary symptoms that point to these conditions 
are dyspnoea and cough. 

Spasmodic dyspnoea is the first and sometimes the only symptom for 
a long time. Later the renal symptoms become pronounced, pointing 
to the true nature of the disease. 

Gastro-intestinal Symptoms. Catarrhal gastritis almost always com- 
plicates nephritis. In addition, gastric symptoms due to uraemia, and 
hence to deficient action of the kidney, ensue. The most common is 
the occurrence of morning nausea or of morning vomiting ; the occur- 
rence of spasmodic vomiting at irregular periods, or the occurrence of 
violent, acute vomiting, which is followed in two or three days by other 
symptoms of uraemia. The patients are usually constipated. When 
the disease is complicated with cirrhosis of the liver, intestinal catarrh 
is common, and intestinal ulceration with consequent diarrhoea is fre- 
quently found. The onset of uraemia may be characterized by violent 
and profuse serous purging, which of itself may cause collapse and death. 

Neuroretinitis is a frequent complication of nephritis, and may 
advance more rapidly than other complications, so that dimness of 



966 SPECIAL DIAGNOSIS. 

vision, blindness, or other eye-symptoms may cause the patient to 
consult an oculist before attention is called to the condition of the 
kidneys. The occurrence of this complication points at once to the 
necessity of an examination of the urine. 

It is common, in the course of an interstitial nephritis, to have acci- 
dents due to the condition of the arteries that accompanies this disease. 
On account of the atheroma, aided by the hypertrophied heart, rupture 
of the vessels frequently takes place. Apoplexy is, therefore, of com- 
mon occurrence, and hemorrhage into other organs sometimes occurs. 

The renal disease is often not suspected until after the patient has 
had an attack of apoplexy. The course of this form of nephritis is 
varied very much by the occurrence of complications, notably em- 
physema, endocarditis, or cirrhosis of the liver. 

Catarrhs. There is always a tendency to chronic inflammations of 
the mucous membranes, and to acute inflammations of serous mem- 
branes in the course of chronic diffuse nephritis. It is necessary, 
therefore, when local inflammations of this character are present, to 
make thorough and repeated examinations of the urine, especially in 
a patient over forty years of age, with a history of one of the causal 
factors previously mentioned. 

Course of the Disease. Several clinical forms of interstitial nephritis 
are observed. In the latent form the disease may have advanced to 
an extreme degree without any symptoms of renal disease during life, 
death taking place from an intercurrent disease or accident. On the 
other hand, palpitation of the heart may be the only symptom com- 
plained of, and the observer finds a hard pulse, general atheroma, and 
hypertrophy of the left ventricle with accentuation of the second sound. 
Apart from this the patient may enjoy very good health. The danger 
lies in the occurrence of pneumonia or inflammation of a serous mem- 
brane. Often the local inflammatory symptoms are slight or masked 
by the symptoms of renal disease, which develop rapidly. 

In another group of cases some special symptom only may be com- 
plained of. In some instances it may be gastric catarrh, in some eye- 
symptoms alone may be present, while in others hemicrania or other 
forms of headache are observed. With the headache there is usually 
vomiting. Again, we may have constant neuralgia or persistent muscu- 
lar rheumatism as the only symptom. Nose-bleed is a symptom which 
may be the only indication of chronic nephritis, particularly if the 
epistaxis occurs frequently. 

In other cases the course is not latent, but characterized by a series 
of attacks at varying intervals. 

During the attacks the symptoms resemble the acute form of neph- 
ritis, with acute uraemia, the occurrence of dyspnoea and loss of appetite, 
nausea and vomiting. The tension of the arteries is higher at the 
time of the attacks. The urine contains albumin, and is of low specific 
gravity during the time of the attack ; during the interval the albumin 
is found at irregular times. 

Suppurative Nephritis (Abscess of Kidney). Infectious matter 
is conveyed to the kidney either Ihrough the blood, as in pyaemia and 
ulcerative endocarditis (rarely dysentery and actinomycosis), or by the 



DISEASES OF THE KIDNEYS. 967 

ureters, as when it follows pyelitis or cystitis. A wound may infect the 
kidney directly. 

Symptoms. The symptoms are those of primary disease, and the 
affection is usually only recognized post-mortem. Or the symptoms 
are merely those of suppuration. Pas is seen in the urine only on 
rupture of the abscess into the pelvis of the kidney. 

Tubercular Nephritis. Fever, emaciation, anaemia, and pros- 
tration characterize the course of the disease. Tuberculosis is usually 
found elsewhere. There may be no other symptoms. Sometimes 
hydronephrosis is present. A tumor is often present. It may be in 
the loins, or may be in front, above, and a few inches to the right 
or left of the umbilicus. The urine is normal or contains pus and 
detritus or even bacilli. The finding of the latter is necessary often 
to establish a diagnosis. In all instances of pyuria renal tuberculosis 
should be suspected. Catheterization of the ureters may disclose the 
organ affected. The urine should then be centrifugalized and the 
sediment examined for bacilli, and, as Reynolds points out, a portion 
inoculated in guinea-pigs. The tuberculin test may be employed. 
The testicles and bladder should be carefully examined for primary 
tuberculosis. 

Tuberculosis of the kidney presents symptoms like those of pyelitis, 
renal calculus, or a new growth. It is almost impossible to distinguish 
any one of the four until an interval has elapsed. In all cases the 
patient suffers from dull pain, sometimes with a bearing-down sensa- 
tion. Hematuria occurs, and the patient is liable to attacks of renal 
colic. These symptoms may continue until a tumor can be made out. 
Even before this pain will be elicited on palpation, which may extend 
all along the urinary tract. With the occurrence of the tumor the 
general symptoms of tuberculosis arise. Further diagnosis is based 
upon the results of the urinary examination. 

The Degenerations. 

Degeneration may be either acute or chronic. The process is always 
secondary, due to the action of inorganic poisons, as arsenic or phos- 
phorus, or the poison of infectious disease, or is produced as the effect 
of chronic disease of the organs, or by disturbance of the circulation. 

In acute degeneration of the kidneys the urine is unchanged, or its 
quantity is diminished. It contains a little albumin, or the albumin is 
present in large amount, with casts and blood-corpuscles. 

There may be no symptoms except changes in the urine, or symptoms 
of uraemia may develop at once. Dropsy and hypertrophy of the heart 
do not occur. 

Chronic degenerations in the kidneys follow chronic congestion, or 
are produced by alcoholism or syphilis. They occur in the course of 
pulmonary phthisis, and of chronic suppuration ; they may develop in 
the course of gout or malarial cachexia. Symptoms : In the simpler 
forms there may be no clinical symptoms whatsoever. In others 
there is loss of flesh and strength, the development of anaemia, and, in 
rare instances, the development of the typhoid state. 



968 SPECIAL DIAGNOSIS. 

The changes in the urine vary. It may be abundant, scanty, or 
suppressed. The specific gravity is not changed, but albumin and 
casts are found. 

Amyloid degeneration of the kidney is associated with similar degen- 
eration in other organs. It occurs in the course of phthisis, of chronic 
suppurations, of syphilis, of chronic dysentery, and is thought to occur 
in the malarial cachexia, or with gout. Symptoms : The degeneration 
may be present without clinical symptoms. If symptoms arise, they 
are due to the anaemia and cachexia that attend the primary disease, 
and to the involvement of the other organs in the same process, as the 
liver, spleen, and intestines. Pnrdy says dyspepsia is prominent and 
diarrhoeal attacks are common. The liver and spleen become enlarged 
during the course of the disease in the majority of cases. (Edema may 
be present, although it is more frequently absent. Uraemia is of rare 
occurrence. In the uncomplicated degenerations there is no hypertrophy 
of the left ventricle, and albuminuric retinitis is a rare complication. 

The Urine. It may be diminished, normal, or increased, usually the 
latter ; it varies from time to time in the same case, depending upon 
complicating symptoms, as diarrhoea, which causes diminished amount 
of urine. It is usually very pale. The specific gravity is not constant. 
It ranges from 1008 to 1014. Albumin is constantly present, and usu- 
ally in considerable amount. Hyaline casts and white blood-cells are 
always found. When other casts are present nephritis probably com- 
plicates the condition. The chief distinctive feature of the casts is their 
large size and hyaline character. 

The diagnosis of amyloid disease is based upon the presence of the 
cause ; changes in the urine ; and signs of similar disease in other organs. 



CHAPTER VIII. 

DISEASES OF THE NERVOUS SYSTEM. 
The Data Obtained by Inquiry. 

The Social History. This includes a knowledge of the patient's 
occupation, whether he or she is married or not, the conditions under 
which he may live, as, for example, in cases of great wealth, there is 
perhaps more tendency or at least more opportunity to dissipation ; in 
conditions of poverty the patient may have been insufficiently nourished, 
or have suffered from continual anxiety. The most important factor is 
probably the occupation. Occupations, from a clinical stand-point, may 
be divided into those that require mental exertion, those that require 
physical exertion, and those that expose the workmen to the possibility 
of Various forms of intoxication. 

The Family History. This is perhaps of more importance in 
connection with nervous diseases than in connection with those of any 
other system. By neurotic heredity we mean the fact that in certain 
families a tendency to the development of various forms of nervous 
disease exists, which may be manifested, however, only in certain mem- 
bers of a given generation. Various terms are employed, to indicate 
the nature of the inheritance. Direct inheritance means that the child 
suffers from exactly the same disease as its parent. If both parents 
have the same disease, the child is likely to have it more severely, and 
this is spoken of as cumulative inheritance. By indirect inheritance is 
meant the condition in which collateral ancestry and not the parents 
have had the disease. Both the parents of the child may appear to be 
healthy, and the grandparents have suffered from the same disease, and 
this is called atavistic inheritance. By similar inheritance is meant the 
occurrence in the offspring of a disease similar to that from which the 
parents have suffered. Examples of such diseases are Huntington's 
chorea, Goldflam's periodic paralysis, etc. By dissimilar inheritance is 
meant the development in the offspring of a form of nervous disease 
differing from that which existed in the parents, as an epileptic child 
born of parents suffering from neurasthenia, hysteria, or insanity. The 
indications of neurotic heredity are manifold. Inquiries must be made 
in regard to cases of insanity, to cases of epilepsy, to instances of suicide, 
to peculiarities of character, to criminal tendencies, to addiction to the 
use of drugs, such as alcohol or opium ; to congenital deformities, or to 
congenital diseases, such as deaf-mutism, etc. Charcot has called atten- 
tion to the fact that certain of the so-called rheumatic manifestations 
may occur in the antecedents of a patient suffering from nervous disease. 

The History of Previous Diseases. This is of considerable im- 
portance. The infectious diseases are sometimes followed by peripheral 



970 SPECIAL DIAGNOSIS. 

neuritis or lesions in the central nervous system, or they may produce 
an early tendency to arterio-sclerosis. It is of importance to know 
whether the fetal existence of the patient was normal, and, if possible, 
to obtain data concerning the condition of the mother during this period. 
Inquiry should be made regarding the nature of the birth ; the existence 
of infantile spasms, at what age they occurred, when. they ceased, if at 
all, and if there was any suspected reason for their development. It 
should be noted when the child first walked, when it first was able to 
talk, the rapidity of its intellectual development and progress at school, 
whether the character was normal, if there were night terrors or noc- 
turnal enuresis. In boys the physician should endeavor to discover if 
there is any history of severe injury, particularly to the head, whether 
the boy had the opportunity for free exercise or was restricted in this 
respect ; if his habits were good ; if he smoked early ; if he was over- 
worked at school or obliged to work hard during early adolescence. 
In the case of females the physician should inquire at what period 
puberty occurred, and whether there has been any difficulty with men- 
struation. The existence of luetic infection is often difficult to eluci- 
date. Occasionally it Avill be admitted, but more frequently it is neces- 
sary to discover the fact by indirect questioning. 

The History of the Disease Itself. As in other conditions, 
the patient should be questioned regarding the duration of the disease, 
its earliest manifestations, whether exacerbations and remissions have 
occurred, and the nature of its course. It is important to inquire for 
slight symptoms that are usually overlooked by the patient, such as 
the ocular disturbances, ptosis, paralysis of the external rectus in loco- 
motor ataxia, a tendency to extravagance in paresis, the manifestations 
of nocturnal epilepsy, etc. 

The Subjective Symptoms. The data obtained by inquiry in- 
clude the subjective sensations of the patient. These are chiefly of 
two kinds — pain and paresthesia. In addition, the patients sometimes 
complain of a general feeling of restlessness, of irritability, of inability 
to think consecutively, or various other forms of indefinite general and 
intellectual disturbance. Pain is, however, such an important symptom 
in general disease that it has been discussed in the section upon Gen- 
eral Diagnosis. 

PARiESTHESi^E maybe defined as subjective sensations, either resem- 
bling those normally occurring as a result of excessive stimulation of 
the sensory nerves, or of a peculiar nature. They are exceedingly 
various in their character, and may be sharply localized or indefinitely 
distributed. To them belong chiefly itching, tingling, formication, 
numbness, subjective sensation of heat or of cold, of moisture, of 
pressure, or of tearing or rending. Sometimes the paresthesia? are 
very slight in character, and may escape the notice of the patient until 
his attention has been directed to them ; in some cases they become so 
severe as to cause intense suffering and temporary helplessness. They 
usually indicate some functional or organic disturbance of a nerve- 
trunk, and are, therefore, as a rule, limited to the distribution of some 
particular nerve. The functional forms, however, may be produced 
by external conditions, such as pressure upon the bloodvessels leading 



DISEASES OF THE NERVOUS SYSTEM. 971 

to a local anaemia, exposure to cold, to heat, and the like. A peculiar 
type of this condition is known as meralgia paraesthetica, and is char- 
acterized by paresthesia in the distribution of the external cutaneous 
nerve of the thigh. In this disease, and occasionally in other forms of 
paresthesia, the subjective symptoms are associated with objective 
disturbances of sensation. 

The Data Obtained by Observation. 

These include nearly all the important symptoms of nervous disease, 
and are, therefore, of paramount importance. They are disturbance of 
sensation, of motion, of reflex action, of appearance and of contour, 
disturbances of the special senses, of the functional activity of the 
various organs of the body, and alteration of the condition of nutrition. 

Sensation. New varieties of sensation appear to be discovered every 
year, and it is therefore tedious and sometimes impossible to analyze all 
that have been already described. Sensations may be described as those 
which are relatively simple — that is, involving but a single variety of 
perception, and those that are complex. 

Simple Sensations. Tactile sensation, or the sense of touch, is 
usually spoken of as sesthesia. It is the ability to know when some 
external object has come in contact with the skin. Hyperesthesia is an 
increased sensitiveness to contact ; and hypcesthesia, decreased sensitive- 
ness ; anesthesia, total loss of the ability to perceive objects touching 
the skin. No satisfactory instrument for the measurement of the touch 
sense has as yet been devised. In general, it may be tested either 
directly with the end of some hard, blunt object, or, when still acute, 
with a camel's-hair brush or cotton point. The patient should close 
his eyes, or, what is better, permit them to be bandaged, and should 
then be instructed to indicate by some word or motion the moment 
contact takes place. The investigator must be careful not to use force, 
and the instrument employed should not be so sharp nor so rough as to 
produce pain. From time to time the patient should be asked whether 
he were touched when contact has not been made, although some move- 
ment indicating the approach of the instrument to the skin has been 
performed. Frequently in prolonged examinations the attention becomes 
fatigued, and the patient no longer recognizes whether he is touched 
or not, and answers at random. Hyperesthesia may occur in a variety 
of conditions. Its most common cause is functional exaltation or irri- 
tability of the nerves, which may occur in neuralgia or neuritis. It also 
occurs in organic disease of the cord, and is then limited to the area of 
distribution of the spinal segment just above the destructive lesion. 
This is spoken of as the zone of hyperesthesia. It is also occasionally 
present in f unctional conditions, such as neurasthenia and hysteria, and 
may be merely the result of some local irritation of the skin. The 
degree of tactile perception varies considerably in different persons. 
Hypcesthesia may occur in a variety of conditions — in neuralgia, in 
partial lesions of the spinal cord, particularly disease of the posterior 
columns, and rarely in central lesions of various kinds, particularly 
those occurring in the parietal lobe, in the end of the posterior limb of 



972 SPECIAL DIAGNOSIS. 

the internal capsule, and in the pons. It also occurs in functional 
nervous conditions, and is quite common among the insane. Ances- 
thesia results from solutions of continuity of the sensory nerves, from 
destructive lesions of the cord, or from central lesions. It is also the 
commonest form of hysterical stigma. Organic anaesthesia may be dis- 
tinguished from functional anaesthesia by its distribution. If caused 
by nerve injury, it will exist in the region supplied by that particular 
nerve. If caused by disease of the spinal cord, the area of anaesthesia 
will be segmental in type — that is, bounded by two nearly horizontal 
lines passing about the body. In unilateral lesions of the spinal cord 
the anaesthesia is limited to the opposite side of the body. In central 
disease the anaesthesia is commonly unilateral, and corresponds to the 
paralyzed side, if paralysis is present. If due to a lesion of the cortex, 
however, it may be limited to one extremity, where it is usually asso- 
ciated with paralysis. 

Pain sense, or algesia, is the ability to perceive pain of any kind. 
Various instruments have been devised for testing its intensity. 
Among the best is that suggested by Kulbin, consisting of a needle 
which is thrust into the skin for varying distances ; the amount of press- 
ure required and the degree of penetration being indicated on a scale. 
Even this, however, is far from accurate, and for clinical purposes it 
is sufficient to use a needle or pinch a small fold of skin between the 
finger-nails. In case of very pronounced disturbance of the pain-sense 
it is sometimes possible to use the actual cautery or to thrust a needle 
entirely through a thick fold of the skin. A faradic current is also 
frequently employed, and to a certain extent is accurate, if data can be 
obtained by comparing the healthy with the diseased side of the body. 
As, however, it appears that there is a special form of sensation for the 
induced current, its results cannot be relied upon implicitly. Hyper- 
algesia, is increased susceptibility to painful impressions, so that the 
lightest contact may cause exquisite agony. It occurs in inflammation 
and in those conditions associated with hyperesthesia. A variety of 
hyperalgesia is tenderness — that is, pain elicited by simple pressure. 
It is most frequently associated with local inflammation, and occurs 
along the course of the nerves in neuritis and neuralgia. Hypalgesia, 
or decreased susceptibility of pain, occurs as a result of partial lesion 
of the nerves, or of the central portion of the spinal cord, and, occa- 
sionally, as a result of focal lesions in the brain. It is also very com- 
mon among idiots, immediately after epileptic attacks, and in cases of 
hysteria. Hypalgesia may also be acquired as a result of constant 
exposure to a mild form of irritation, as, for example, in those accus- 
tomed to going bare-footed. Analgesia is an exceedingly important 
symptom. It results from total destruction of the nerve ; from disease 
of the central gray matter of the spinal cord, such as occurs in trans- 
verse myelitis, syringomyelia ; in tumors of the cord ; and from focal 
disease of the brain, particularly if situated in the parietal lobe, and 
the posterior limb of the internal capsule. It also occurs in a great 
variety of functional conditions, and may be general in the form of 
insanity known as primary stupor. It is a very common lesion in 
hysteria, and in this disease the area of distribution may assume the 



DISEASES OF THE NERVOUS SYSTEM. 973 

most curious forms, being limited to one-half of the body, or tracing 
geometrical figures on various parts of the skin. It may also be pro- 
duced by hypnotic suggestion. Organic analgesia is frequently associ- 
ated with trophic changes, either as a result of the inability of the part 
to defend itself against irritation, or as a result of the intimate associa- 
tion of the sensory and trophic nerve-fibres. 

Visceral pain may be elicited by strong pressure upon the testicles, 
ovaries, or breasts, or a violent blow upon the abdomen. It is usually 
characterized by intense prostration and nausea. Visceral analgesia 
occurs in some cases of locomotor ataxia and occasionally in hysteria. 

The heat sense, or thermocesthesia, enables us to recognize the differ- 
ence in temperature between various bodies. It is usually tested by 
filling two test-tubes, one with hot and one with cold water, and apply- 
ing them in irregular alternation to the region under investigation. 
The difference in temperature between the two tubes is a rough test 
of the delicacy of the sense. In health a difference of 1° C can be 
recognized upon the more sensitive portions of the body (the ante- 
rior surface of the forearms, the skin of the face, and the chest). A 
rougher test is the use of metal and wooden objects. The former con- 
duct heat more rapidly from the surface, and therefore give rise to a 
sensation of cold. The heat-sense is rather complicated, and is not yet 
thoroughly understood. There seem to be special points upon the skin 
where the nerves for heat and cold terminate. (Goldscheider.) There 
may be loss of perception for cold objects, while the perception for hot 
objects remains unimpaired, or the reverse may be present. Sometimes 
the patient calls all objects warm and at other times he calls them cold. 
Hyperthermocesthesia is practically of no value as a clinical sign, for our 
methods of testing the delicacy of the sense are at present imperfect, 
and hypothermowsthesia is also difficult to detect, and probably belongs 
to the category of conditions in which one of the sensations is more or 
less impaired. Thermoanesthesia, or complete loss of the heat-sense, 
is very important clinically. It occurs in neuritis or destructive lesions 
of the nerve, and in central disease of the spinal cord, such as transverse 
or pressure myelitis, tumor, and especially in syringomyelia. As a 
result of being most frequently associated with cord disease, the thermo- 
ansesthetic area is usually segmental. The heat-sense may, in connection 
with other forms of sensation, be diminished in functional nervous 
disease. 

The above three forms of simple sensation are those usually regarded 
as of the greatest clinical importance. They may be equally affected, 
or one or two may be preserved and the others diminished or lost. 
The latter condition is known as dissociation of sensation. It occurs 
in neuritis, but is exceedingly rare. It also occurs in various forms of 
myelitis, particularly pressure myelitis. It is the most characteristic 
symptom, and for a long time was considered pathognomonic of syringo- 
myelia. In this form of dissociation tactile sense is preserved, and the 
temperature and pain senses are lost. When the tactile sense is lost, and 
the pain sense still present, the condition is termed ancesthesia dolorosa. 

Simple sensations of perhaps less clinical importance than the fore- 
going are trichocesthesia, or the consciousness that a cutaneous hair has 



974 SPECIAL DIAGNOSIS. 

been touched. This is really the sensation perceived when tactile sense 
is tested with the cotton point ; the latter is felt very well upon the 
forearm, on the back of the hand, and not on the palm, where sen- 
sation is distinctly more acute. Von Bechterew calls attention particu- 
larly to the fact that trichosesthesia and tactile sense are not equally 
delicate in various parts of the body. The former is most readily 
tested by touching the individual hairs with a small needle or cotton 
point. More elaborate apparatus of no particular value has, however, 
been devised. 

The Sensation of Locality. When any part of the surface of the body 
is touched we can, under normal conditions, tell the location of the 
point of contact. This varies, however, consideraoly in various parts 
of the body, being more accurate on the lips and less on the skin of 
the back between the shoulder blades, where an error of from 6 cm. 
to 7 cm. is still within the normal limits. It may be very much dis- 
turbed without any loss of the delicacy of the touch sense. It may be 
tested by making contact with the finger or any blunt object. Another 
method formerly much used by clinicians, and still employed by psy- 
chologists, is the use of the ossthesiometer, an instrument consisting 
essentially of two points that can be placed at a measured distance 
from each other. It has been found that in normal persons these can 
be detected as two points at the tip of the tongue when separated only 
1 mm. ; but may still be felt as one on the back when separated as much 
as 65 mm. This method is extremely inaccurate, for the reason that 
it is difficult to apply the points with the same degree of force. More- 
over, experiments have shown that the skin readily becomes educated 
and able to discriminate points much closer together than is normal 
for the, part that is being tested. 

AUochiria. This is a general term applied to the false localization of 
sensory stimuli. In some cases the sensation may be felt not at the 
point where it was applied, but at exactly the corresponding point on 
the opposite side of the body. This occurs particularly in hysteria. 
In organic disease of the spinal cord mistakes of localization are not 
uncommon — thus, in hypaesthesia of the arm, irritation at the hand 
may be referred to the shoulder, and the same is true of the lower 
extremity. 

When there exists a hypsesthesia it is of course difficult for the 
patient to localize as accurately as is possible when sensation is normal. 

The Electro-cutaneous Sense. This is really the degree of resistance 
to the irritation of the induced current. It varies considerably in 
different individuals, and in the same individual under different con- 
ditions and in different parts of the body. It is perhaps most delicate 
on the skin of the face, and least delicate on the back and the outer 
surface of the thighs. It is curiously affected in certain nervous dis- 
eases ; thus, in the periodic paralysis of Goldflam it is almost completely 
abolished during the attack. In meralgia paraesthetica it is also, as a 
rule, greatly diminished. In all cases of muscular degeneration the 
electric current is better supported than when the muscles react. It 
is also greatly diminished when there is oedema of the skin or much 
subcutaneous fat. It sometimes persists, however, when tactile anaes- 






DISEASES OF THE NERVOUS SYSTEM. 975 

thesia is present. In tetany it is greatly exaggerated (Erb's sign), and 
this constitutes one of the cardinal symptoms of the disease, and it is 
also increased in some of the functional nervous conditions. It is best 
tested by using a simple faradic battery, employing as the electrode 
for contact either the wire brush or the naked wire. No satisfactory 
system of measurement has as yet been devised, but it is of advantage 
to use invariably the same battery, and to note the position of the inner 
coil with reference to the outer one. 

Pressure Sense. The clinical significance of this has not yet been 
determined. It is certain, however, that it undergoes considerable 
variation as the result of various pathological changes. It may be 
tested roughly by making various degrees of pressure with the finger 
or a blunt object upon the surface of the skin, the limb being so placed 
that it is impossible for the patient to make muscular resistance. It 
may be tested more accurately by using a series of little blocks that 
can be piled one on top of the other, or by filling a vessel more or less 
completely with shot or mercury. 

Functional Modifications of the Various Forms of Sensa- 
tion. Delayed Sensation. The perception of the various forms of 
stimulation that are appreciated in consciousness as sensations may 
be delayed for some time after the stimulus has been applied. This 
is spoken of as delayed sensation, and the interval may, in extreme 
cases, be several seconds. It is not known where this delay takes 
place, whether in the sensory bodies of the skin, or in the nerves, or in 
the central nervous system. This symptom is manifested particularly 
in tabes dorsalis, but may occur in functional nervous disease and in 
various forms of organic central disease. It has also been noted in 
peripheral neuritis. The delay can occur for one sensation alone, as 
the pain sense, even when tactile sense is normal. 

Complex Sensations. These are probably very numerous, but 
only two have been so carefully studied that they are valuable for 
clinical purposes. These are the so-called position or muscular sense, 
and the stereognostic sense. By the position or muscular sense we mean 
the ability to perceive and recognize the position of the limbs or of the 
body — that is, whether, for example, the joints are in a state of flexion 
or extension, supination, pronation, or rotation ; whether the spine is 
bent or erect, and the position of the head with reference to the trunk. 
It probably depends upon the complex co-ordination of the perceptions 
received from the muscles, joints, periosteum, tendons, and skin. It 
may be tested in a variety of ways. The patient should be instructed 
to close his eyes or have them bandaged ; the finger is carefully grasped 
on either side and flexed or extended. After each movement the patient 
indicates its direction. After the fingers have been tested the same 
process is employed for the wrist, elbow, and shoulder. Similar methods 
may be used for the feet, and the head may be rotated to the right or 
the left, bent forward, laterally, or backward. Another method is to 
take one arm, bend it into some particular position, and instruct the 
patient to imitate the position with the other arm ; the same thing being 
done with the legs ; or the patient may be instructed to describe the 
position in which his arm has been placed, without attempting an imi- 



976 SPECIAL DIAGNOSIS. 

tation. This sense is lost when for any reason there is total anaesthesia 
of the part, and may disappear as an isolated symptom in case of disease 
of the posterior columns or in the ataxia due to central lesions. By 
the stereognostie sense we mean the ability to recognize the shape, 
consistency, surface, and nature of any object placed in the hand or 
brought in contact with the skin of any part of the body. This sen- 
sation is most readily tested by directing the patient to keep the eyes 
firmly closed; then to select a number of small objects, such as a 
pencil, match-safe, coin, key, etc., and place them in his hand and 
direct him to name them or describe them. This sense depends upon 
a variety of perceptions. The size of the object is recognized by a 
combination of the locality and muscle senses ; the nature of its surface 
by the tactile sense ; its consistency chiefly by the pressure sense, per- 
haps aided by the pain-sense ; its nature — that is, whether of metal, 
wood, or any other substance — largely by the temperature sense. The 
stereognostie sense is always abolished when tactile sense is absent. 
Occasionally in hysteria the patient may declare himself unable to 
perceive touch when the stereognostie sense is intact, but this is an 
exception. It may, however, be lost when tactile sense is still preserved, 
especially if the locality sense and the muscle sense have been greatly 
impaired. When due to organic causes its absence usually indicates a 
lesion in the parietal lobe or in the projection fibres coming from this 
region. It occurs frequently in hemiplegia, in cerebral monoplegia, 
and occasionally in peripheral palsy, involving two forms of sensation. 
It has also been observed as a transient symptom after brain shock 
without disturbance of any other sense. 

Disturbance of Motility. These may be grouped under a number 
of heads. First, loss of power, which may be either partial, paresis ; 
or complete, paralysis. Second, impairment of movement, inco-ordina- 
tion, or ataxia. Third, closely allied to this, tremor. Fourth, excessive 
muscular movement, spasm, or convulsions. 

Paralysis. This is a loss of power in the muscles. It may be 
true, in which the loss of power is due to some disease of the muscle 
itself or the nervous influence controlling it ; or false, when it is due 
merely to an inhibition of the muscular function produced by a disease 
of the muscle or joint that causes pain upon movement. Paralysis is 
classified, according to the part affected, into monoplegia, when one 
extremity is involved ; hemiplegia, when half the body is involved ; 
paraplegia, when two symmetrical extremities are involved ; para- 
plegia cruralis, if the legs are affected ; paraplegia brachialis, if the 
arms are affected (this term is usually restricted clinically to paralysis 
of both legs) ; diplegia, when two extremities are affected without 
involvement of the trunk. Clinically, this is sometimes restricted, 
although incorrectly, to paralysis of both arms (diplegia brachialis) or 
of both sides of the face {diplegia facialis). Crossed paralysis is a term 
applied to paralysis of one side of the face and the opposite side of the 
body. Local paralysis is the term used when only small groups of 
muscles are affected. Multiple paralyses is employed when several 
parts of the body are involved at the same time. Paralysis is also 
classified, according to the cause, into cerebral paralysis, spinal parol- 



DISEASES OF THE NERVOUS SYSTEM. 977 

ysis, neural paralysis, and muscular or myopathic paralysis. Paralysis 
is also classified, according to the type, into spastic paralysis, in which 
the muscle tone is increased and the reflexes are exaggerated, and con- 
tractures are either present or likely to ensue, and flaccid paralysis, in 
which the muscle tone is diminished, in which there is no resistance to 
passive movement, and the reflexes are abolished. Spastic paralysis is 
usually due to some lesion in the central motor neuron — that is, between 
the motor cortex and the terminations of the fibres of the pyramidal 
tracts in the anterior cornua of the spinal cord. The lesion, therefore, 
may be situated in the cortex, the corona radiata, the internal capsule, 
the pons, the pyramids of the medulla, and the lateral columns of the 
cord. Spastic paralysis must not be confused with the contractures 
that ensue after degeneration of the muscles, as in infantile palsy, 
neuritis, etc. In these cases the limbs are in a state of permanent 
flexion. The resistance to extension and to passive movement is not 
due to increased muscular tone, but to an actual shortening of the 
muscle and its tendons, which can only be overcome by rupture of one 
or the other. Flaccid paralysis may be produced by cerebral lesions, 
but is more commonly due to lesions of the peripheral motor neurons 
— that is, from the anterior cornua of the cord to the muscle itself. 
It may, therefore, be produced by destruction of the ganglion cells, by 
injury to the anterior roots, or the peripheral nerves, or disease of the 
muscle. Flaccid paralysis frequently occurs as the result of functional 
conditions — for example, it is the type of paralysis that is usually 
observed in hysteria. As the trophic centres influencing the muscle 
are either cut off or destroyed, atrophy of the latter usually takes place 
(atrophic paralysis), which is characterized by decrease in bulk, altera- 
tion of the electrical reactions, and fibrillary twitchings. Monoplegia, 
or paralysis of one limb, may be caused by small lesions in the cerebral 
cortex or the corona radiata. It is rarely produced by lesions of the 
internal capsule, where the fibres are placed closely together, or of 
the spinal cord, unless the gray matter of the latter is involved. It 
occurs in circumscribed forms of infantile paralysis, in lesions of the 
peripheral nerves, particularly the roots of the plexuses, but rarely in 
disease of the muscles alone, the lesions in this case being more widely 
distributed. Monoplegia also occurs in hysteria and in the pseudo- 
paralysis due to localized disease of the muscles or joints. Hemiplegia 
is commonly due to a lesion of the opposite side of the central convolu- 
tions. This lesion may either be extensive and destroy the motor por- 
tion of the cortex or corona radiata, or more circumscribed, involving 
the internal capsule, the crura, the pons, or the medulla. Spinal lesions, 
also, if unilateral, which is rare, and situated above the fourth cervical 
segment, may produce paralysis of the same side of the body. ( Vide 
Brown-Sequard's syndrome.) In hemiplegia due to lesion of the cere- 
brum, the muscles of the trunk, and those supplied by the upper 
branch of the facial nerve commonly escape. The lower half of the 
face, the arm and leg, and the side of the body opposite the affected 
hemisphere are paralyzed. If due to lesion of the pons below the 
decussation of the facial fibres — that is, in the posterior half — the arm 
and leg of the opposite side and the lower half of the face on the 

62 



978 SPECIAL DIAGNOSIS. 

same side are paralyzed {crossed paralysis, pontine palsy). Lesions of 
the medulla ordinarily, in addition to the motor tracts, involve other 
important nuclei and tracts. Spinal hemiplegia is characterized by 
the absence of facial involvement. Hysterical hemiplegia can only be 
recognized in some cases by the discovery of the other stigmata of that 
disease. The form of paralysis in organic hemiplegia is ordinarily 
spastic, and usually in the coarse of time pronounced contractures 
occur. Paraplegia cruralis is usually produced by a lesion of the spinal 
cord. If this lesion is situated above the lumbar portion of the cord, 
the type of paralysis is spastic ; if in the lumbar or sacral region, or 
involving the cauda equina, there is often abolition of the reflexes and 
flaccidity of some of the muscles. Paraplegia, therefore, occurs in trans- 
verse or pressure myelitis, in tumor of the spinal cord, in hemorrhage 
into the spinal cord, and as a result of traumatism. It is occasionally 
produced by multiple neuritis of the legs, particularly that form known 
as Landry's paralysis, or in alcoholic neuritis, by bilateral cerebral 
lesions, and occasionally as a functional condition. Paraplegia brachi- 
alis is a rare condition occurring chiefly as the result of a localized 
meningitis in the cervical enlargement, particularly pachymeningitis 
hypertrophica cervicalis. As the result of the destruction of the ante- 
rior roots there is atrophy and degeneration of the muscles, and the 
paralysis is flaccid. It may also occur in syringomyelia, and more 
rarely as a result of traumatic injury to both sides of the brachial 
plexus. Diplegia facialis is almost invariably the result of bilateral 
facial palsy — that is, either neuritis or an injury to the facial nerve 
after it leaves the medulla. The paralysis is, therefore, flaccid in 
type, characterized by the loss of the normal folds, and the inability to 
close the eyes and drooping of the corner of the mouth. 

Multiple palsies are usually due to some general condition affecting 
the peripheral neurons — thus, in multiple infantile palsy the anterior 
cornua of the gray matter of the spinal cord are involved in various 
situations. The paralysis is usually flaccid and incomplete — that is, 
certain groups of muscles escape. In polyneuritis due to intoxication 
or infection there may be paralysis either of certain groups of muscles, 
particularly the extensors, or of the entire limb. This occurs most 
frequently in poisoning by lead, arsenic, and alcohol, or in infectious 
diseases, as beri-beri and diphtheria. The paralysis is nearly always 
flaccid ; there is muscular atrophy, and the reactions of degeneration 
ultimately appear. Local palsies are usually due also to lesions of the 
peripheral neurons. Occasionally, however, a very small lesion in the 
cortex will produce this condition. They are commonly the result of 
some trauma injuring a single nerve-trunk. The paralysis is, of course, 
flaccid, and the reactions of degeneration are present. 

A congenital absence of complete atrophy of the muscle gives rise 
to myopathic paralysis. In either case the diagnosis must usually be 
made by careful anatomical examination, as in the course of a very 
short time the patient learns to compensate the defect of the individual 
muscle by the excessive action of others in its neighborhood. The 
muscles most frequently affected by congenital absence are the pec- 
torals, although many others also may be involved. Total atrophy 



DISEASES OF THE NERVOUS SYSTEM. 979 

occurs in various myopathies, but with extreme slowness. In a special 
type of muscular atrophy (type of Duchenne-Aran) atrophy occurs in in- 
dividual muscles or in small groups, and compensation is usually acquired 
for a considerable time until the progress of the disease renders it no 
longer possible. 

Paresis is a term used to indicate partial loss of power in the volun- 
tary muscles. In addition to the causes given for paralysis, it may be 
produced by exhaustion. Paresis is of two kinds — that in which the 
muscle is unable to exert its normal force at any time, and that in 
which the muscle may exert its normal force for a brief period and 
then rapidly becomes exhausted and insufficient. In the former there 
is some deformity, such as foot-drop or wrist-drop. In the latter the 
symptoms do not appear until some effort has been made. Paresis 
may also be temporary, as after fatigue ; stationary, as in cases of 
injury to the central nervous system ; or progressive, as in the myop- 
athies. In the latter condition the muscles waste and lose their 
power, but reactions of degeneration do not occur, and there are no 
fibrillary twitchings. Ultimately, the condition may go on to absolute 
paralysis. The power of the muscle may be tested very accurately by 
means of the dynamometer. This consists of a steel spring with a 
staff on one side and a sliding index on the other. The patient com- 
presses the spring in the palm of the hand, and the amount of pressure 
is indicated in pounds or kilogrammes upon the index. By various 
mechanical devices the dynamometer may also be employed for the 
other muscles of the body. Care should be taken when it is used that 
the patient is not permitted to throw his weight against it. In using 
the instrument it is chiefly important to regard not so much the abso- 
lute power as the difference between the two sides, the degree of mus- 
cular force normally present varying very greatly in different indi- 
viduals. Clinically, it is often sufficient to have the patient squeeze 
the physician's hand first with one hand and then with the other ; even 
moderate differences being readily detected by this means. The patient 
may also be instructed to resist passive movements, such as the exten- 
sion of the flexed arm ; the flexion of the extended arm ; the lateral 
movement of the head ; the opening of the eyelids, or the various 
movements of the lower extremities. 

Intermittent claudication is a term applied to indicate the occurrence 
of transient, partial, or complete paresis or lameness. Sometimes the 
patient will suddenly be unable to continue locomotion, and fall to the 
ground ; at others, one limb will become weak, causing a pronounced 
limp and necessitating the aid of a crutch ; while in other instances 
there is simply discomfort upon continued locomotion. This symptom 
occurs in various forms of functional nervous diseases ; thus the peri- 
odic paralysis of Goldflam, meralgia paraesthetica, and as an idiopathic 
condition in diabetes and arterio-sclerosis. 

Disturbances of movement, characterized by excessive or perverted 
muscular activity, consist of ataxia, tremor, and spasm. By ataxia 
is meant the inability to co-ordinate perfectly — that is, to give each 
muscle its due share in the performance of any action. As a result 
the movements are irregular and imperfect. Various types of ataxia 



980 SPECIAL DIAGNOSIS. 

have been distinguished : Spinal ataxia, in which the disturbances of 
motion are more pronounced when the eyes are closed, and which is due 
to disease of the posterior columns ; cerebellar ataxia, in which the dis- 
turbances are equally severe when the eyes are opened or closed, but 
disappear when the patient lies down ; cerebral ataxia, in which there 
is loss of muscular sense and marked persistent inco-ordination of 
movement, occurs as a result of injury to the parietal lobe ; pseudo- 
ataxia, due to the weakness of certain groups of muscles, so that they 
do not properly oppose the action of other groups. Finally, there is 
a form of ataxia apparently due to anaesthesia of the skin and loss of 
the muscular sense, in which the patient is able to perform movements 
perfectly as long as he can watch the part with the eye, but as soon 
as the eyes are closed the ataxia appears Ataxia may be tested in a 
variety of ways. Ataxia of the upper extremities may be recognized 
by directing the patient to touch the tip of the nose with the tip of 
the forefinger, or to extend the arms and bring the tips of the 
forefingers together with a rapid motion. In health, after one or 
two trials, either of these movements can be done perfectly. When 
ataxia is present they are carried out awkwardly, and the forefingers 
are only brought in contact with each other or the tip of the nose after 
several irregular coarse oscillations. The ataxia of the legs may be 
tested by requesting the patient, lying upon his back, to touch some 
object held above his feet with one of the toes, or to bring the heel of 
one foot against the knee of the other. When the patient is erect the 
ataxia may be tested by getting him to place the feet together, when 
there may be some SAvaying that is usually very markedly increased 
when the eyes are closed. If the ataxia is very slight it may be neces- 
sary to get the patient to stand on one foot with the eyes closed, or 
to attempt to step backward under the same conditions. Under these 
circumstances a considerable swaying occurs that is more pronounced 
than the swaying noticed in a normal person attempting to perform 
the same movements. If the ataxia is at all pronounced it produces a 
characteristic disturbance in the gait. (See Ataxic Gait.) Ataxia of 
the head is difficult to detect. Some observers contend that a peculiar 
form of grimacing, whenever the patient attempts to move the lips or 
the eyes, or whenever the muscles of the face express some emotion, is 
an ataxic condition due to overaction. 

Tremor. This is a disturbance of motion characterized by an oscilla- 
tion of the part or parts involved. Tremor may be of various kinds. 
It may be fine or coarse, constant or irregular. It may disappear 
upon voluntary effort or only be apparent when motion is attempted 
{intention tremor). It may be the result of paralysis, paralytic tremor ; 
of poisoning, toxic tremor ; of some functional nervous disease, as the 
hysterical tremor ; or spasm of the muscle, spasmodic tremor ; or it may 
occur as a family peculiarity without any discoverable cause, hereditary 
or idiopathic tremor. Tremors are also classified as rapid, in which the 
movements occur more than five times per second ; and slow, in which 
the oscillations may occur at intervals of several seconds. Nearly all 
forms of tremor are increased by placing the muscles upon a stretch. 
Tremor can usually be recognized by simple inspection. In some cases 



DISEASES OF THE NERVOUS SYSTEM. 981 

it is necessary to use peculiar methods of detecting it. Ordinarily it is 
sufficient, in order to detect tremor of the fingers, to get the patient to 
extend them forcibly and keep them in that position. If the tremor, 
however, is exceedingly fine, its effect may be exaggerated by attaching 
long, light rods to the fingers, such as straws. This procedure is often 
exceedingly useful in cases of tremor of the head or the feet. Tremors 
may be recorded by attaching to the part affected rods whose ends are 
furnished with a pencil or stylet which writes upon a moving roll of 
paper. If a chronograph marks off seconds or fractions of a second 
at the same time, it is possible to measure very accurately the rate of 
oscillation. A more convenient method consists in allowing the patient 
to put the trembling part, for example, the hand, upon a small drum 
which conveys each movement to an oscillatory stylet that marks upon 
a piece of smoked glass or paper. Seconds should be marked at the 
same time. Persistent fine tremor occurs particularly in paralysis 
agitans. In this the movements in the fingers are those of flexion 
and extension and of opposition in the thumb, and it has, therefore, 
been spoken of as the pill-rotter's tremor. It also occurs not infre- 
quently in exophthalmic goitre and as hereditary or idiopathic tremor. 
Irregular tremors occur as a manifestation of ataxia, often with cere- 
bral lesions (the paralytic tremor), and after intoxications, as alcohol 
and tobacco. The hysterical tremor may be either irregular or regular. 
Its character is largely influenced by surrounding circumstances ; thus 
if the hysterical patient be in the hospital Avard and have an oppor- 
tunity of seeing a case of paralysis agitans, the tremor peculiar to that 
condition is often closely reproduced. Ordinarily, however, the hys- 
terical tremor, being the result of voluntary and variable effort, is 
irregular. Intention tremor occurs particularly in multiple sclerosis. 
In this condition no tremor is observed while the parts are at rest, but 
as soon as voluntary motion is attempted a violent tremor ensues, and 
continues until the effort ceases. Such a tremor can be particularly 
well elicited by asking the patient to convey a glass of water to his 
mouth. The movements become more and more violent as the lips are 
approached, and frequently more or less of the water is spilled. It may 
also be tested by asking the patient to touch with the forefinger some 
object. It will be observed, as the finger approaches, that the oscilla- 
tions become more vigorous and wider. Intention tremor may, of 
course, be present in other parts of the body. Generalized tremors 
are spoken of as convulsions or convulsive movements (g. v.). 

Muscular Spasm. By this is meant a condition in which the 
muscle is involuntarily but forcibly contracted, either persistently 
(tonic or tetanic spasm) or rhythmically (clonic spasm). Tonic spasms 
are characterized by the vigorous contraction of the muscle, which 
becomes hard and painful. If only one group of muscles is affected, 
as, for example, the calf, the joint controlled by this group is placed in 
the position normally assumed when they are active. If all the muscles 
of the limb or even antagonistic groups are affected, the flexors usually 
overcome the extensors. This, however, is not invariably the case. 
When all the muscles of the body are involved, the powerful muscles 
of the back usually arch the spinal column, and there is a more or less 



982 SPECIAL DIAGNOSIS. 

severe opisthotonos. Tonic spasms can usually be diagnosticated by 
simple inspection. They occur particularly in tetanus, strychnine- 
poisoning, and hysteria, and in these conditions may often be produced 
by peripheral irritation. Localized spasms in the upper extremities 
may occur as a result of disease of the cord above the cervical enlarge- 
ment, or of the brain, producing a spastic condition of the muscles. 
This is rare. A more common type is the peculiar form of spasm 
seen in tetany, consisting in the closure of the fingers and the opposi- 
tion of the thumb, giving rise to the so-called obstetrical hand. Spasms 
in certain individual muscles of the hand or arm occur in the occupation 
neuroses. Spasms of the lower extremities are also occasioned by the 
various conditions giving rise to spasticity of the muscles. An idio- 
pathic form of spasm not infrequently occurs in the calf muscles, par- 
ticularly on awakening. It appears to be of no clinical significance. 
Hysterical spasms are of various types. The tonic forms may affect a 
single limb or even a single group of muscles, and may persist for long 
periods of time, giving rise either to extension or persistent flexion of 
the limb. In the latter case shortening may ultimately ensue and 
cause persistence of the deformity. General hysterical spasms usually 
can be recognized by the fact that the patient assumes some extraor- 
dinary posture, as opisthotonos, pleurosthotonos, and emprosthotonos. 
These spasms are often precipitated by pressure upon some sensitive 
point (hysterogenic zone, ovaria), and may sometimes be abolished 
by pressing upon the same or a corresponding portion of the body. A 
peculiar form of localized tonic spasm is that occurring in the masseters, 
known as trismus. The myotonic reaction is frequently spoken of as a 
form of tetanic spasm. It consists of a sudden, persistent contraction 
of the muscle or groups of muscles with which some voluntary move- 
ment has been attempted. It occurs, as far as is known, only in Thorn- 
sen's disease. Clonic spasms are of various types. They may affect a 
single extremity, half the body, or, in rare cases, the whole body. The 
movements are usually rhythmical, and vary greatly in different cases. 
The most frequent causes of clonic spasms are the injuries to the brain. 
Focal irritation in the motor region will produce at first a spasm in the 
part innervated by that area. If the irritation is sufficiently strong, or 
acts for a sufficiently long time, its influence will extend to the adjacent 
areas in the cortex, and a general unilateral or bilateral convulsion will 
ensue. This is the so-called epileptiform attack. If the local spasm 
is distinct and precedes by some time the development of the general 
twitching, it is spoken of as focal, or Jacksonian epilepsy. As a result 
of the violent irritation in the brain, unconsciousness usually ensues, 
but not invariably. Clonic convulsions may possibly be of local origin, 
although this is exceedingly doubtful. Ankle clonus, however, and 
patellar clonus bear a certain resemblance to this symptom of disease. 
A localized form of clonic spasm, due to peripheral irritation in all 
likelihood, is facial tic, characterized by occasional or successive light- 
ning-like contractions of the muscles of the face. Functional con- 
vulsions, particularly those occurring in hysterical patients, are very 
frequently clonic in character. Often there will be a preliminary 
tetanic spasm, followed in a short time by the development of clonic 



DTSEASES OF THE NERVOUS SYSTEM. 983 

movements. These assume various forms, the commonest being per- 
haps beating with the limbs, throwing of the head from side to side, 
and lateral or antero-posterior movements of the body. The attitudes 
and movements express fear, threat, ecstasy, eroticism, or other emo- 
tional states. 

Allied to the clonic spasms, but bearing also close affinity to tremors, 
are the irregular movements that occur in chorea and athetosis, i The 
typical movement of chorea is an irregular innervation of groups of 
muscles that appears to be voluntary in character, but that is not under 
the control of the patient, is much more rapid, as a rule, than a volun- 
tary movement, and recurs at very frequent intervals. Choreic move- 
ments may be mild, or so severe that they produce irregular contortions 
of the body, causing the patient to throw himself or herself from side 
to side, and often producing severe bodily injuries and even death by 
exhaustion. Athetosis is a name given to a peculiar, slow, irregularly 
rhythmical movement of the extremities, generally spoken of as worm- 
like in character. It is ordinarily most marked in the fingers. In 
movement these are gradually extended until they form almost a right 
angle with the back of the hand, and then slowly flexed and extended 
again, each finger moving more or less independently of the others. 
At the same time there is movement at the wrist- joint, the elbow, and 
sometimes of the trunk. The limbs may be affected, giving rise to a 
curious, staggering gait in which the patient seems ever to be about to 
lose his equilibrium, but maintains it almost by a miracle. Frequently 
the muscles of the face are involved, giving rise to curious, irregular 
grimaces and more or less disturbance of speech or dysarthria. The 
movements are usually continuous. Athetosis is a very common sequel 
to cerebral lesions occurring in early childhood. 

The term convulsion is used to designate general spasm with loss of 
consciousness. It is often employed, however, to indicate general clonic 
spasm of the whole body, even if consciousness be still present. This 
use is undesirable, and should be avoided. General convulsions inva- 
riably indicate some disturbance in the brain. If this is organic, it 
may be either some chronic disease with occasional exacerbation of 
cortical irritation, or some acute injury or some disease, such as men- 
ingitis. If it is some functional disturbance, it may be hysteria or 
epilepsy. (The latter is, of course, usually due to organic lesions.) 

The term muscular tone means that condition of the voluntary 
muscles of the body by which they are maintained in a state of tension 
sufficient to enable them to respond promptly to nervous innervation. 
Muscular tone varies slightly under normal conditions. It is less in 
profound fatigue, and when the attention is distracted by external 
objects ; it is more marked when the patient concentrates his attention 
upon the part being tested. It is invariably diminished after lesions 
of the peripheral motor neuron, in cases of profound cachexia, in coma, 
and during anaesthesia. It is also generally decreased in lesions of the 
posterior columns of the spinal cord. It is increased in lesions of the 
central motor neuron without involvement of the peripheral neuron, in 
neurasthenia, hysteria, and in conditions affecting the brain as a whole, 
such as meningitis, brain tumor, etc. It must be remembered that 



984 SPECIAL DIAGNOSIS. 

flaccid paralysis does not necessarily imply diminished muscle tone ; 
thus in the early stages of hemiplegia the muscles are completely 
relaxed, but, nevertheless, the reflexes are usually increased. There 
are two methods of testing this quality : First, passive movements ; 
second, the tendon reflexes. In the former the limb to be tested is 
grasped firmly, and, if flexed, is suddenly but not too forcibly ex- 
tended, or, if extended, is flexed. If the muscle tone is normal there 
may be a transient, involuntary resistance at first, but this disappears 
very soon, and then the limb may be moved in any position with com- 
paratively slight effort. Any of the joints may be tested independently 
in this manner. It is important to inform the patient what is to be 
done and what is to be tested. In children, in the ignorant, and in the 
insane it is often almost impossible to overcome the tendency to volun- 
tary resistance, which is usually increased by the anxiety produced by 
the examination. Occasionally it is necessary to take some measures 
to distract the attention, such as giving the patient a sum in arithmetic 
to perform, requesting him to look at the ceiling or some particular 
object, or engaging him in conversation. Increase of the muscle tone 
is determined by increased resistance to passive movements. This may 
be so great that it is almost impossible to bend the limb at any of the 
joints, or so slight that it is difficult to discriminate it from the normal 
condition. 

The exaggerated forms are usually spoken of as spasticity of the 
muscles, and when associated with paretic or paralytic conditions the 
term spastic paralysis is employed. Diminution of the muscle-tone is 
usually difficult to detect by passive movements alone. When it is 
entirely lost the limb is spoken of as flail-like. The joints seem to 
have no tendency to remain in one position. If the limb is shaken, 
with every movement they pass from extension to flexion, or vice versa. 
Under these circumstances the passive movements are entirely unre- 
sisted, the only effort necessary being that required to overcome the 
weight of the limb itself. 

The Texdox Reflexes. These were first described by Westphal 
in connection with the reflexes of the knee. They consist essentially 
of a rapid twitch or succession of twitches in the muscle when the 
tendon by which it is attached to some bony part is struck a sharp 
blow. There is some difference of opinion regarding the true nature 
of the stimulus required to produce them. According to Gowers, it is 
a simple extension of the muscle, and he, therefore, uses the term myo- 
tatic phenomenon. Sternberg, on the other hand, believes that he has 
shown that they are the result of vibrations in the tendon, which are 
communicated by it to the muscle. Others contend that they are pure 
reflexes produced by the mechanical action of the blow upon the nerve- 
fibres in the tendon itself. It is certain, at any rate, that more factors 
are required than the mere tone of the muscle, and that afferent im- 
pulses to the spinal cord and efferent impulses from it are necessary to 
the development of the reflex ; and that it is furthermore profoundly 
influenced by higher centres that usually have an inhibitory action 
(upper reflex arc). The question is complicated by the fact that in 
certain cases the reflexes may be elicited by tapping the bony parts, such 



DISEASES OF THE NERVOUS SYSTEM. 985 

as the periosteal reflexes ; by irritating the skin overlying the muscles, 
as the cutaneous reflexes ; or by tapping upon the fascia or the belly 
of the muscle itself. In general, it may be said that all conditions pro- 
ducing increased muscular tone produce exaggeration of the reflexes, 
and that all conditions diminishing muscular tone diminish the reflexes. 
In marked contradiction to this, however, are the facts that attention to 
the reflex, being tested, vvill diminish or abolish it completely, whereas 
distraction of the attention, which ordinarily diminishes muscular tone, 
increases the force of the reflex. Moreover, in certain forms of pro- 
found coma, where the muscle tone appears to be at a minimum, the 
reflexes appear to be often greatly exaggerated. Thus, in uraemia and 
diabetic coma, I have been able on several occasions to detect exaggera- 
tion of the reflexes when the limbs were flail-like in their relaxation. 

The individual reflexes of the head are practically limited to the chin- 
jerk. This is elicited by having the patient open his mouth slightly, 
then a flat object, such as a tongue depressor, or the handle of a spoon, is 
placed upon the teeth of the lower jaw and sharply tapped with the 
finger or hammer. Under normal circumstances there will be a slight 
upward jerk of the chin. It may also be elicited with less discomfort 
to the patient by placing the finger beneath the lower lip and upon the 
mental prominence and striking it sharply with the hammer. This does 
not always result in a reflex under normal conditions, but is quite satis- 
factory for the purpose of testing pathological exaggeration. The chin- 
jerk is nearly always increased in neurasthenia and hysteria, and is 
sometimes present in profound coma. In the conditions of general 
spasticity that are occasionally met with in severe infectious disease it 
is also usually exaggerated. Its absence does not appear to be of any 
pathological significance. Allied to the tendon or peritoneal reflexes 
is the phenomena known as Chvostetis sign. This occurs only in tetany, 
and consists of a sudden lightning-like twitching of the muscles of the 
face, particularly the elevators of the angles of the lip and the muscles 
of the eyelids. It is elicited by striking the skin below the zygomatic 
arch just in front of the ear with the hammer. It was formerly sup- 
posed that this was due to mechanical irritation of the trunk of the 
facial nerve, but the same phenomenon can also be elicited by striking 
over the malar bone or in the region of the infra-orbital foramen. No 
tendon reflexes have as yet been discovered for the muscles of the 
trunk. 

In the arms the most important are the bicipital, tricipital, and 
the supinator reflexes. The bicipital reflex is best obtained by allow- 
ing the patient to rest the perfectly relaxed arm upon some support, 
for example, the arm of the investigator in a semi-flexed position. 
The finger or thumb is then placed upon the tendon of the biceps, and 
struck a sharp blow with the hammer or the finger, as in percussing. 
In nearly all normal cases a slight twitching or distinct contraction of 
the biceps can be obtained in this manner. Sometimes it is possible, 
by resting the arm upon a support, to see the tendon distinctly and to 
strike it directly, but this is usually much less satisfactory. The tri- 
cipital reflex is readily obtained by holding the arm semi-flexel and 
relaxed, and then striking just above the olecranon process of the ulna. 



986 SPECIAL DIAGNOSIS. 

The supinator reflex is obtained by striking the radius just above the 
styloid process. These reflexes are particularly distinct in hemiplegia, 
upon the paralyzed side. They also occur in the general conditions 
above mentioned. Their absence is of no pathological significance, as 
it is often impossible to obtain them in normal individuals. In addi- 
tion a reflex may be obtained by striking the bodies of the extensor 
muscles of the forearm, giving rise to extension of the fingers. A 
form of wrist clonus occasionally occurs that may be elicited by sud- 
denly flexing the wrist-joint either dorsally or ventrally, and holding 
it in the cramped position. The hypothenar reflex is the contraction 
produced in the palmaris brevis by pressure upon the pisiform bone. 
It does not appear to be dependent upon any diseased condition. Tap- 
ping upon the bodies of the muscles sometimes gives rise to a sharp 
contraction. This is particularly observed in connection with the 
shoulder muscles (Striimpell) and pectoral muscles. An important 
reflex, the abdominal reflex, is elicited by drawing the end of a blunt 
object obliquely across the skin of the abdomen downward and out- 
ward or upward and inward, the object being to make it cross the line 
of the intercostal nerves as nearly as possible at a right angle. This 
produces contraction in the muscles innervated by these nerves, and 
is due to the stimulation of their cutaneous distribution. It may be 
exaggerated in functional nervous conditions, and is diminished in 
cases of hemiplegia and anaesthesia on the anaesthetic sides. Its absence 
at some particular point occasionally serves as an additional factor in 
the localization of lesions of the spinal cord. Various reflexes, prob- 
ably periosteal or fascial in nature, may be produced by tapping upon 
the spinous processes of the ilium. As far as is known, they are not 
of any clinical value. 

The reflexes of the lower extremities are the most important of 
all. The first discovered, the knee-jerk, is invariably present in health, 
and by its delicacy and constancy is the most valuable reflex for clin- 
ical purposes. It may be elicited in a variety of ways. Perhaps 
the best method is to have the patient lie upon his back ; then placing 
one hand under the knee it should be lifted several inches from the 
surface of the bed or table until the leg and thigh form an obtuse 
angle of about 120°. Then with the finger, the side of the hand, 
the edge of the stethoscope, or the percussion hammer 1 it is struck a 
sharp blow. The patellar tendon should be struck between the lower 
edge of the patella and the tuberculum of the tibia. The stroke should 
be delivered with moderate force, and, according to the practice of most 
clinicians, a single blow is sufficient, but sometimes the reflex is more 
certainly elicited if several strokes are given in quick succession. The 
most obvious and vigorous contraction occurs in the quadriceps of the 
same side, causing the leg to be tipped upward suddenly and giving 
rise to the name knee-jerk. In addition, the adductors of the same side 
nearly always contract slightly, and occasionally the flexor muscles — 

1 There are various forms of these — one with a heavy metal head and short, wooden 
handle, the end of the metal head being covered with leather ; another, composed of a 
wedge-shaped piece of rubber set in a light metal handle ; the latter is probably the 
better. 



DISEASES OF THE NERVOUS SYSTEM. 987 

that is, the biceps, the semi-tendinosus, and the semi-membranosus — 
also contract. Frequently the adductors of the opposite side contract 
very slightly in health, and sometimes quite vigorously in diseased 
conditions (crossed-reflex). Other methods of obtaining this reflex are 
to allow the patient to sit on a low chair with the leg extended forward, 
until it forms a blunt angle with the thigh, with the heel resting upon 
the ground. The patellar tendon is then struck as before. Clinically 
it is usually sufficient when the patient is sitting in an ordinary chair 
to have one leg thrown over the other, and hanging loosely and freely. 
Occasionally it is difficult, on account of extreme relaxation of the 
muscles, to stretch the tendon sufficiently to obtain the reflex by this 
method, and Gowers suggests that under these circumstances the legs 
should be completely flexed upon the thighs. It is often difficult to 
discover the tendon, either on account of deformity of the joint or 
because of an excess of fat tissue. In one case that I have observed, 
in which extensive arthropathies existed, the knee-jerk was present, 
but obtained with great difficulty, on account of the distortion of the 
parts. The patellar tendon reflex, therefore, is a multiple muscular 
reflex, producing phenomena of the opposite side, the so-called bilateral 
reflex. .It is said to be invariably present in health, but its intensity 
varies considerably, and in some apparently healthy persons without 
any evidence of disease of the spinal cord it is extremely difficult to 
elicit. Under these circumstances it is necessary to use various pro- 
cedures in order to make it evident. These consist either in requesting 
the patient to look at the ceiling, in order to distract the attention, or 
to perform some violent muscular effort, such as an attempt to pull the 
hands apart when they are clasped together, to squeeze the dynamom- 
eter, etc. Under these circumstances the knee-jerk, if obtained, is 
spoken of as reinforced. It is always important to have the muscles 
completely relaxed, and to prevail upon the patient not to think of 
what is being done. The knee-jerk is sometimes rendered more pro- 
nounced by emotion, and sometimes inhibited, as, for example, by 
fright. The arc of the knee-jerk is situated in the first lumbar seg- 
ment of the cord, but probably occasionally deviates slightly from this 
position, being either higher or lower. The knee-jerk is, therefore, 
invariably increased in any disease of the pyramidal tracts above this 
point. It is diminished in disease of the efferent or afferent fibres. 
Its absence in tabes dorsalis was noted early, and has long been con- 
sidered evidence of disease of the posterior columns. Closely allied to 
the knee-jerk in its clinical significance and mode of occurrence is the 
patellar reflex. This is elicited usually by placing the finger transversely 
above the patellar, pushing the bone forcibly down, and then striking 
the finger with the hammer. Ordinarily a distinct, pronounced con- 
traction of the quadriceps alone is produced. In order to elicit this 
reflex the leg must be extended and relaxed. Patellar clonus occasion- 
ally occurs, and is obtained by placing the thumb and forefinger on the 
upper edge of the patella and pushing it forcibly downward and keep- 
ing it in that situation. If clonus occurs it will be characterized by a 
series of rapid contractions of the quadriceps, resulting in a vertical 
oscillation of the patella. It occurs in disease of the spinal cord, and 



988 SPECIAL DIAGNOSIS. 

not infrequently in conditions of increased tonicity in general infectious 
diseases. 1 

In general it ma} 7 - be said that the mechanical effort is dependent 
upon the condition of the nutrition of the quadriceps and the amount 
of interference of the opposing muscles. Exaggeration of the knee- 
jerk is characterized by a more vigorous effort or more extensive con- 
traction of the surrounding muscles. The latter, indeed, may, by the 
involvement of the flexors, diminish the excursion of the leg. Some- 
times in cases of profound emaciation, as in cachexia, although the 
knee-jerk is increased and the muscle apparently contracts vigorously, 
its power is so greatly diminished that it is unable to move the leg. 
Elaborate mechanisms, therefore, that have been devised for meas- 
uring the knee-jerk do measure in fact only the amount of movement 
of the foot, and are practically worthless. They consist essentially of 
an arc of a circle whose radius is approximately equal to the length of 
the leg. Either a pencil or a small readily movable index is placed 
agaiust the foot, and the knee-jerk is measured by the number of de- 
grees marked off on the scale. It is manifest that comparisons are 
only valuable when the blow is of exactly the same force, and then 
only when the experiments are performed upon the same individual 
within a limited period of time. In order to obtain a constant force 
of blow various instruments have been devised, the simplest being 
weights dropped through a paper cylinder upon the patellar tendon, 
and the more complicated having springs for their motive power. 
Tendon reflexes may also be obtained by tapping upon the hamstring 
tendons. They are of no particular value. Tapping upon the inner 
condyle of the tibia often produces contraction of the adductor muscles, 
but this is not, as a rule, as pronounced as the contraction produced by 
the percussion upon the patellar tendon. Next in importance to the 
patellar reflex is the Achillis tendon reflex, which consists of the contrac- 
tion of the gastrocnemius and soleus muscles when the Achillis tendon 
is struck. It is most readily elicited by lifting the entire leg from the 
bed or table, and holding it by the ball of the foot, which is gently 
pressed upward. The tendon is thus moderately stretched, and may 
be struck directly. In nearly all healthy individuals this reflex is 
present, but is absent in some, and its absence is apparently of no clin- 
ical significance. Exaggeration may be indicated in moderate cases by 
the more forcible extension of the foot. In more pronounced cases it 
gives rise to a peculiar and characteristic phenomenon, known as ankle 
clonus. This may be elicited by tapping the tendon once vigorously or 
several times in succession when the leg is held in the manner described, 
but is more readily produced by slightly flexing the leg and thigh, then 
grasping the ball of the foot firmly, flexing it dorsally with considerable 
force, and holding it in that position. When ankle clonus exists there 
will be violent vibratory oscillations of the foot, as long as the pressure 
upon the sole is continued, that vary from two to three up to five or 

1 Dr. Mills has devised an ingenious instrument, consisting of a metal ring with a 
curved handle, by which the patella may be drawn downward and the jerk or clonus 
more certainly elicited. 



DISEASES OF THE NERVOUS SYSTEM. 989 

ten movements per second. There is usually a rhythmical increase and 
decrease in the rapidity, without absolute cessation at any time. Occa- 
sionally, in very mild cases, the clonus after a few movements becomes 
weaker, and rapidly disappears. Ankle clonus is supposed to indicate 
the existence of a lesion above the second lumbar segment of the spinal 
cord that seriously interferes with the function of the pyramidal tract. 
For a long time there has been doubt as to whether it occurs in func- 
tional disease, but it seems now to be established that it does. Its 
occurrence in functional conditions is, however, of such extreme rarity 
that when it is present organic disease should always be suspected. It 
is most characteristic in spastic paraplegia, either due to transverse 
myelitis, to lateral sclerosis, or to syringomyelia. It also occurs after 
lesions in the motor regions of the brain. It can sometimes be elicited 
by supporting the weight of the leg upon the toe. Under these circum- 
stances it develops spontaneously in organic conditions, and sometimes 
in fatigue, cold, or exhaustion. It may also be produced in normal 
persons who continue for a sufficient length of time voluntary oscilla- 
tory movements of the foot supported in this manner. A pseudo-ankle 
clonus has been described as characterized by a few irregular oscilla- 
tions that soon cease. It occurs in functional disease and occasionally 
among malingerers. Tapping upon the tendon of the great toe occa- 
sionally produces a slight contraction of that member. The other 
reflexes of the lower extremities are front tap, dorsal extension of the 
toes upon percussion of the anterior surface of the tibia, and the toe 
reflex — that is, slight flexion of the toes when the skin of the sole is 
irritated. This, according to Babinsky, is replaced by a dorsal flexion 
of the toes when the pyramidal columns are involved, and disappears 
in tabes dorsalis. The plantar reflex properly belongs to the group of 
cutaneous reflexes. It is characterized by the involuntary withdrawal 
of the foot when the sole is irritated. It is of course absent in cases 
of anaesthesia, and is greatly exaggerated in functional nervous condi- 
tions, occasionally giving rise to a peculiar general tremor of the leg or 
even of the whole body. It is best elicited by drawing a blunt object 
(pencil, handle of a stethoscope) across the surface of the foot. 

Allied to the reflexes is the so-called paradoxical contraction of "West- 
phal. This consists in a persistent spasm of the muscle when its two 
attachments are suddenly brought closer together. It is most fre- 
quently observed in the peroneal muscles of the leg, and may be elicited 
by suddenly flexing the foot dorsally. It occurs most frequently in 
various functional conditions, and has also been observed in paralysis 
agitans. 

!Next to the functional conditions of the muscles, which is indicated 
by the degree of motility that they possess, we are interested in the 
state of their nutrition. It may be suspected that this is impaired 
when fibrillary contractions or atrophy are present. 

Atrophy of the muscles may usually be detected by simple inspection. 
If only certain groups are involved, the latter will appear more or less 
distorted. It is always, however, important to measure the injured 
limb and compare it with the sound side if the affection is unilateral. 
When due to general conditions, such as the muscular dystrophies or 



990 



SPECIAL DIAGNOSIS. 



polyneuritis, it is sometimes more difficult to be certain of its existence. 
A general atrophy of the muscular system also occurs in cachectic 
states, such as the cachexia of carcinoma. Fibrillary twitchings occur 

They are characterized 



in muscles undergoing degenerative changes. 

© © © © 



Fig. 226. 



M. occipit. 

M. retrah. auric. 
N. auricul. post. 

M. splenitis 

N. accessorius 

M. sternocleidom. 

M. cucullaris 

N. axillaris (M. deltoid.) 

N. thoracic, long. (M. serr. 
ant. maj. 

Plexus brach. 




M. temporal. 
M. frontal. 

M. corrugator super- 

[cilii. 
M. orbicul. palp. 

Nasal muscles. 



jM. levat. lab. sup. 
M. zygomaticus. 

>■ M. orbic. oris. 

M. masseter. [talis. 
M. levator menti (men- 
M. depressor lab. inf. 

(quadr. menti). 
M. depressor ang. oris 

(triangul. menti). 



N. hypoglossus. 



Platjsma 
M. sternohyoideus. 
M. oniohyoideus. 
N. phrenicus. 

M. sternothyreoideus. 

Erb's point (M. del- 
toid., biceps, brach. 
int. supinator long. 

N. thoracic ant. (M. 
pect. maj.). 



Motor points for the head and neck. (Sahli.) 



by the sudden, spasmodic contraction of individual fibres in the mass 
of the muscle itself, giving rise to a curious trembling of the overlying 
skin and a peculiar sensation to the palpating hand, as if minute waves 
were passing through the muscular substance. They often occur spon- 
taneously, and in degenerating muscles may be elicited by slight median- 



DISEASES OF THE NERVOUS SYSTEM. 991 

ical stimuli, such as cold, percussion, or shock. Fibrillary twitchings 
may also occur in healthy muscles that have either been chilled (tremor 
or shivering) or subjected to severe fatigue. 

The most reliable method of diagnosis is by an electrical examina- 
tion. For this purpose we use two types of apparatus. The galvanic 
current is produced by the galvanic battery, consisting of a number of 
cells, each containing an electro-positive and electro-negative element 
and filled with battery fluid. Long wires are attached to the battery, 
through which the current flows when they are brought in contact or 
the circuit closed, and ceases when they are kept apart or the circuit 
opened. The free end of the wire toward which the current flows 
from the cell is called the anode, and the free end from which the 
current passes to the cell, the cathode ; then, if any substance is intro- 
duced between these ends of the wire, closing the circuit, the current 
passes through it from the anode or positive pole to the cathode or 
negative pole. It is customary to introduce into the circuit for meas- 
uring the amount of electricity employed a galvanometer, which is 
graduated in milliamperes. 1 As it is important to employ a definite 
number of milliamperes, the apparatus is also provided with a rheostat, 
which renders it possible by the introduction of a greater or less degree 
of resistance to regulate the amount of electricity passing through the 
body. The free ends of the wire are, for medical purposes, supplied 
with electrodes. These consist essentially of metal disks or plates 
to which the wire is attached, provided with a wooden or hard rubber 
non-conducting handle. As the resistance normally offered by the 
skin is greatly reduced if it be moistened, the ends of the electrodes 
are covered with cotton or gauze and moistened by immersion in either 
plain or salt water. The area of the cross-section of the electrode may 
vary considerably. Ordinarily, it is customary to have one very large 
electrode, from 50 to 100 square centimetres in area, and one exactly 
3 square centimetres in area. (Stintzing 7 s standard electrode.) In 
addition, for therapeutic purposes, it is customary to have for the 
galvanic and faradic apparatus a wire brush and various special elec- 
trodes for application to the more inaccessible portions of the body. 
If a muscle or nerve is to be investigated the large electrode is thor- 
oughly moistened and placed over the back or the sternum. It is 
not advisable to place it over the neck nor to allow the patient to hold 
it in the hand. The current is so arranged that this large electrode is 
at first the anode and the small electrode the cathode. The cathode 
is now placed over the muscle or the nerve to be stimulated, locating 
it, if possible, exactly over the most sensitive (electrically) point. This 
is most readily determined by comparison with the figures on pages 990 
et seq. The circuit should be open and the rheostat so placed that the 
minimum amount of current flows through the body. The circuit is 

1 One milliampere equals 0.001 of an ampere. The ampere is the unit adopted for 
the measure of the amount of current. It is determined by dividing the unit of 
electromotive force, one volt— that is, 0.9 of the amount of current liberated by a 
freshly filled Daniell cell, divided by 1 ohm — that is, the amount of current required 
to overcome a unit of standard resistance, or a column of mercury 1.06 metres in 
length and 1 square millimetre in cross-section. 



992 



SPECIAL DIAGNOSIS. 



now rapidly opened and closed, while the cathode is kept in position 
and the rheostat gradually moved around until the current is strong 
enough to produce a slight twitching of the muscle. This will first 
occur at the making of the circuit, and is spoken of as cathodal closing 
contraction, or CCC. The current should now be slightly increased, 
and by means of a switch the small electrode converted into the anode 
and the other into the cathode. It will soon be observed that a con- 
traction takes place both at opening and closing the current. This is 
spoken of as the anodal closing contraction, or ACC, and the anodal 
opening contraction, or AOC. If the small electrode be again made 

Fig. 227. 



Rectus abdominis. 
Intercostal nerves. 




Serratus magnus. 
Latissimus dorsi. 



Intercostal nerves. 



Transversus 
abdominis. 



Diagram of the motor points of the trunk. (From Von Ziemssen.) 



the cathode, it will be found that there is a vigorous contraction when 
the current is closed, but none when it is opened. Finally, if the cur- 
rent is made still stronger, it will be found that the closure of the 
current produces at the cathode no longer a simple lightning-like con- 
traction, but a prolonged cramp of the muscle, spoken of as cathodal 
closing tetanus, or CCTe. The contraction produced by both opening 
and closing the current at the anode is now much stronger than before, 
and there will probably appear a slight contraction at the opening of 
the cathode, the cathodal opening contraction, or COC — that is to say, 
with gradual, increasing current the order of contraction is as follows 
in a normal muscle : cathodal closing contraction, anodal closing con- 
traction, anodal opening contraction, cathodal closing tetanus, cathodal 



DISEASES OF THE NERVOUS SYSTEM. 



993 



opening contraction. Under ordinary circumstances the healthy muscle 
contracts suddenly and relaxes almost immediately. Various modi- 
fications of these phenomena occur in diseased conditions, and there are 
considerable quantitative changes between the different muscles in 
health. Thus, in the muscles of the face contraction is always more 




2 4 

Diagram of the motor points of the arm, under side 
1. Musculocutaneous nerve. 2. Musculocutaneous nerve, 
triceps. 6. Median nerve. 8. Brachialis anticus. 10. Ulnar nerve 
nerve to the pronator teres. 



(From Von Ziemssen.) 
3 Biceps. 4. Internal nerve of 
12. Branch of median 



rapid than in those of the thigh, and can be elicited with much weaker 
currents. In disease we recognize three types of alteration : First, 
quantitative changes ; second, quantitative qualitative changes ; third, 
pure qualitative changes. Before discussing these it is necessary to 
describe the faradic apparatus. This consists essentially of a coil of 
wire through which flows an electric current, that forms the core for a 




Motor points of the arm, outer side. (From Von Ziemssen.) 

1. External head of triceps. 2. Musculo-spiral nerve. 3. Brachialis anticus. 4. Supinator 

longus. 5. Extensor carpi radialis longior. 6. Extensor carpi radialis brevior. 

second coil not attached to it. If, now, the current passing through 
the inner or primary coil is interrupted, there will be generated, at each 
opening of the current, a current in the outer or secondary coil, going 
in the opposite direction, and, at each closure, a current going in the 
same direction. This is usually the stronger, and, if the interruptions 

63 



994 



SPECIAL DIAGNOSIS. 



are sufficiently rapid, dominates the reversed current. The ends of the 
secondary coil are attached to the electrodes. The strength of the cur- 
rent is altered by moving the inner coil away from the secondary coil. 



Fig. 230. 



Fig. 231. 





Motor points of forearm, inner surface. Motor points of forearm, outer surface. 

(From Von Zi ems sen.) 

Fig. 230.— 1. Flexor carpi radialis. 2. Branch of the median nerve for the pronator teres. 3. 
Flexor profundus digitorum. 4. Palmaris longus. 5. Flexor sublimis digitorum. 6. Flexor 
carpi ulnaris. 7. Flexor longus pollicis. 8. Flexor sublimis digitorum (middle and ring fingers). 
9. Median nerve. 10. Ulnar nerve. 11. Abductor pollicis. 12. Flexor sublimis digitorum (index 
and little finger). 13. Opponens pollicis. 14. Deep branch of ulnar nerve. 15. Flexor brevis 
pollicis. 1G. Palmaris brevis. 17. Adductor pollicis. 18. Adductor minimi digiti. 19. Lumbri- 
calis (first). 20. Flexor brevis minimi digiti. 22. Opponens minimi digiti. 24. Lumbricales 
(second, third, and fourth). 

Fig. 231.— 1. Extensor carpi ulnaris. 2. Supinator longus. 3. Extensor minimi digiti. 4. Ex- 
tensor carpi radialis longior. 5. Extensor indicis. 6. Extensor carpi radialis brevior. 7. Extensor 
secundi internodii pollicis. 8. Extensor communis digitorum. 9. Abductor minimi digiti. 10. 
Extensor indicis. 11. Dorsal interosseus (fourth). 12. Extensor indicis and extensor ossis meta- 
carpi pollicis. 14. Extensor ossis metacarpi pollicis. 16. Extensor primi internodii pollicis. 18. 
Flexor longns pollicis. 20. Dorsal interossei. 






DISEASES OF THE NERVOUS SYSTEM. 



995 



This is spoken of as the distance between the coils, and is measured in 
inches or centimetres. It is manifest that this method for measuring 
is not absolute, but its value must be determined for each particular 
machine. This can only be done by the physiological test — that is, 
measuring the force required to produce contractions in some muscles 
and then comparing it with the known value for this muscle obtained by 
a standard machine, and obtaining in this way the ratio. The current 



Fig. 232. 



Fig. 233. 





Motor points of thigh, anterior surface. Posterior surface. 

(From Von Ziemssen.) 

Fig. 232.— 1. Tensor vaginae femoris (branch of superior gluteal nerve). 2. Anterior crural nerve. 
3. Tensor vaginae femoris (branch of crural nerve). 4. Obturator nerve. 5. Rectus femoris. 6. Sar- 
torius. 7. Vastus externus. 8. Adductor longus. 9. Vastus externus. 10. Branch of crural nerve 
to quadriceps extensor cruris. 12. Crureus. 14. Branch of crural nerve to vastus externus. 

Fig. 233.— 1. Adductor magnus. 2. Inferior gluteal nerve for gluteus maximus. 3. Semi-tendin- 
osus. 4. Great sciatic nerve. 5. Semi-membranosus. 6. Long head of biceps. 7. Gastrocnemius 
(internal head). 8. Short head of biceps. 10. Posterior tibial nerve. 12. Peroneal nerve. 14. Gas- 
trocnemius (external head). 16. Soleus. 



is, of course, increased Jwhen the secondary coil is directly over the 
primary one and diminished when the primary coil is withdrawn. As 
the current in the secondary coil is oscillatory — that is, going first in 
one direction and then in the other — it is not theoretically possible to 
speak of an anode and a cathode. Practically, however, the current 
going in the same direction as that of the primary coil is the stronger, 
and a difference does exist between the two ends of the wire, which are 



996 



SPECIAL DIAGNOSIS. 



usually spoken of, therefore, as cathode and anode. A contraction pro- 
duced by the faradic stream is always tetanic in health, as there are a 
series of stimulations constantly passing through the muscle. 



Fig. 234. 



Fig. 235. 





Motor points of the leg, outer side. Inner side. 

(From Von Ziemssen.) 
Fig. 234.— 1. Peroneal nerve. 2. Peroneus longus. 3. Gastrocnemius (external head). 4. Tibi- 
alis anticus. 5. Soleus. 6. Extensor longus pollicis. 7. Extensor communis digitorum longus. 
8. Branch of peroneal nerve for extensor brevis digitorum. 9. Peroneal brevis. 10. Dorsal inter- 
ossei. 11. Soleus. 13. Flexor longus pollicis. 15. Extensor brevis digitorum. 17. Abductor 
minimi digiti. 

Fig. 235.— 1. Gastrocnemius (internal head). 2. Soleus. 3. Flexor communis digitorum longus. 
4. Posterior tibial nerve. 5. Abductor pollicis. 



Alterations in the Reactions of the Muscles and Nerves 
to Electricity. Reactions of Degeneration. Quantitative 
alterations consist in increase or decrease of the susceptibility of the 
muscles or nerves to electrical action. They may be determined in 
case the lesion is unilateral by comparison with the normal side of the 
body ; in case the lesion is bilateral, only by comparison with a stand- 
ard table, such as has been furnished by Stintzing. If the deviation 



DISEASES OF THE NERVOUS SYSTEM. 



997 



from the normal is slight, the error has very likely been produced by 
variation or alteration in the resistance of the skin. Quantitative 
increase in the electrical reaction occurs chiefly in tetany, for which 
disease it is almost pathognomonic, and has been spoken of as Erb's 
sign. It occurs also occasionally in the early stages of hemiplegia, in 
paralysis of the facial nerve, and has been noted in certain cases of 
tabes dorsalis. Diminished electrical irritability occurs in all the forms 
of idiopathic muscular dystrophy. It also occurs in those forms of 
atrophy due to lesion of the central motor neuron without involve- 
ment of the peripheral motor neuron. It also occurs in those atrophies 
secondary to disease of the joints and loss of functional activity on the 
part of the muscle. Diminished reaction may occur in hysteria and 
profound neurasthenia, and has been observed in some cases of loco- 
motor ataxia, and even in some cases of progressive spinal muscular 
atrophy of exceedingly slow course. It also occurs in certain nervous 
diseases whose nature is not yet understood, as in Goldflam's periodic 
paralysis, although it is to be noted that there are other alterations in 
the electrical reactions in this disease. The quantitative qualitative reac- 
tion consists, first, of a diminution of the reaction of the muscle or the 
nerve to the faradic current, and its diminution or exaggeration to the 
galvanic current, with distinct alteration of the order in which the 
various forms of galvanic irritation produce contractions. Cohn dis- 
criminates three types of this form of degeneration : First, the complete 
reaction, mild in character, and terminating in recovery ; second, the 
complete reaction, severe and incurable ; and, third, a partial reaction. 
He gives the following table illustrating the various stages of these three 
forms : 

Total Beaction of Degeneration. 



Moderate Form. 
Indirect stimulation (nerve). 



Direct stimulation (muscle). 





F. 


G. 


F. 


G. 


1st stage, 1-8 days. 


Diminished. 


Diminished. 


Diminished. 


Diminished. 


2d stage, 2-15 weeks. 


Lost. 


Lost. 


Lost. 


Increased, con- 
traction slow. 
AOC>CCC. 


3d stage, 6-30 weeks. 


Returning. 


Returning. 


Returning. 


Diminishing 

contraction 

more rapid. 

AOC = or 

>CCC. 


4th stage, later. 


Subnormal. 


Subnormal. 


Subnormal. 


Subnormal, no 
qualitative 
changes 




Progressive 


Incurable Form. 




1st and 2d stages. 


As first and second stages above. 




3d stage, after 6 weeks. 


Lost. 


Lost. 


Lost. 


Diminished 
or lost. 
AOOCCC. 



1 By direct stimulation is meant the application of the electrode to the muscle itself- 
By indirect stimulation is meant the application of the electrode to the motor nerve- 
trunk. The latter term is employed because irritation of the nerve can only be detected 
by the activity of the muscle, and the stimulation of the latter is, of course, in this 
mode of application, indirect. 



998 



SPECIAL DIAGNOSIS. 



Partial, Reaction of Degeneration. 

Indirect stimulation (nerve). Direct stimulation (muscle). 



1st stage, 1-S days. 
2d stage, 2-5 weeks. 



3d stage, 6-12 weeks. 
3d stage, 6 weeks. 



Normal or 
diminished. 

Normal or 
diminished. 



G. 
Normal or 

diminished. 
Normal or 

diminished. 



Normal or 
diminished. 
Normal or 
diminished. 



All normal or progressive form. 
Diminished Diminished Diminished 
or lost. or lost. or lost. 



G. 
Normal or 
diminished. 
Increased, con- 
traction slow. 
AOCXCCC. 

Diminished 

or lost. 
Contraction 
still slow. 

AOC<CCC. 



The following points in these tables need explanation. The faradic 
reaction is similar to that which occurs in the ' normal muscle, but 
requires a much stronger current to produce it. The galvanic reaction 
of the nerve is similar to that obtained under normal conditions, except- 
ing that a stronger current is required. The contraction is lightning- 
like and disappears instantly. The direct galvanic stimulation of the 
muscle, however, produces a worm-like contraction very different from 
that observed in the normal muscle, and is ascribed to the direct stimu- 
lation of the muscle itself and not to the stimulation of thet erminations 
of the motor nerves. This often occurs with a much weaker current 
than is normally required to produce contraction in the muscle. It 
Avill also be observed that the cathodal closing contraction is no longer 
the first to appear, but it is replaced by the anodal opening contraction, 
and this is followed by the anodal closing contraction, cathodal closing 
contraction occurring only with relatively strong currents. If regen- 
eration occurs muscular contractions occur in response to weaker faradic 
currents, and by direct galvanic stimulation they become more light- 
ning-like in character. Gradually the cathodal closing contraction 
appears in response to weaker currents, and finally occurs before the 
anodal opening contraction. If recovery does not take place, direct 
galvanic stimulation requires stronger and stronger currents, and there 
is no increase in the rapidity of the contraction. The cathodal closing 
contraction disappears, and finally only the anodal contraction remains, 
which is exceedingly slow and worm-like. When the muscle-tissue has 
been completely replaced by connective tissue all reactions naturally 
cease. The partial reaction of degeneration is very similar to the mild, 
complete form. Recovery, however, occurs, as a rule, very rapidly. 
The reaction of degeneration may be used for determining the prog- 
nosis of the case. When after the sixth week the muscle does not 
respond as readily as before to direct galvanic stimulation, and the 
cathodal closing contraction becomes equal to or greater than the anodal 
opening contraction, the prognosis is exceedingly favorable. Particu- 
larly the increased rapidity of the contraction is of great significance. 
If, on the other hand, after from six to twelve weeks no change has 
occurred and the anodal still precedes cathodal contraction, and both 
arc worm-like in character, the prognosis is doubtful. Months, how- 
ever, may elapse before the muscle gradually begins to regain its normal 



DISEASES OF THE NERVOUS SYSTEM. 999 

character. The voluntary contractions of the muscle, as a rule, persist 
after the reaction of degeneration has become manifest, unless, of course, 
there has been total destruction of the peripheral motor neurons. Often 
in cases of peripheral neuritis it Avill be observed that the reaction of 
degeneration is present in muscles that are apparently healthy, but 
which, when the process is progressive, subsequently atrophy. When 
regeneration occurs voluntary motion will have been almost completely 
restored long before the muscle has become entirely normal, and it 
may often reappear before any improvement can be detected in the 
electrical reactions. In testing these reactions the following points are 
to be noted : First, the reaction of the nerve to faradic and galvanic 
electricity ; second, the reaction of the muscle itself. It is particularly 
important to be certain that only the muscle under investigation is 
affected by the electrical current. Sometimes it will be impossible to 
accomplish this, but ordinarily it can be done sufficiently well to enable 
us to secure positive results. It must be remembered, however, that 
the reactions of degeneration often occur in the muscles of limbs that 
have been injured, or are found in limbs in which some of the groups 
of muscles have already undergone atrophy, and thus altered the ana- 
tomical relations. Under these circumstances mistakes are very likely 
to arise. Sometimes valuable information can be obtained by stimu- 
lating a nerve-trunk and observing whether all the muscles innervated 
show normal or impaired contractility. Quantitative and qualitative 
reactions of degeneration occur primarily as a result of disease of the 
peripheral motor neuron. They are, therefore, found in all diseases of 
the spinal cord that affect the anterior cornua or the motor roots, and 
in all diseases of the medulla that affect the motor nuclei or their roots ; 
therefore, in acute and chronic antero-poliomyelitis, progressive spinal 
muscular atrophy, in bulbar palsy, in transverse myelitis, syringo- 
myelia, tumor of the cord, and as a result of chronic forms of menin- 
gitis, or disease of the vertebral columns pressing upon the roots. 
They are also found in all forms of peripheral neuritis, either the 
toxic, the infectious, or the traumatic, and in all cases of solution of 
continuity of the nerves. They occasionally occur in the so-called 
idiopathic muscular dystrophies, but in these they are exceptional. 
They are also fouud in a few cases after cerebral lesions. 

Atypical Types of the Reaction of Degeneration. Only two of these 
are important. First, the myotonic reaction, consists of the persistence 
of the muscular contraction after the electric stimulus has been removed. 
This occurs either with the faradic or the galvanic current, but the order 
of contraction to the various forms of stimulation of the latter is not 
altered. This reaction is pathognomonic of Thomsen's disease — myo- 
tonia congenita. It is more likely to occur as a result of stimulation 
of the muscle itself than of stimulation of the nerve. Second, the 
myesthenic reaction is characterized by the rapid exhaustion o£ the 
muscle or the nerve, so that relaxation may take place while the faradic 
current is still being employed, and if the muscle is stimulated succes- 
sively several times, it loses its power to contract or requires a stronger 
current. It occurs in periodic family paralysis. Remak and Marino 
have described a peculiar form of reaction which they name the neuro- 



1000 SPECIAL DIAGNOSIS. 

tonic reaction. It consists of the persistence of the contraction only 
after stimulation of the nerve. 

Disturbances of Speech. These may be divided into two groups : 
aphasia, the disturbance of the central nervous mechanism controlling 
speech, writing, and mimicry ; and anarthria, the disturbance of the 
peripheral motor mechanism of speech. 

By aphasia is meant the loss or impairment of the ability to under- 
stand spoken, written, or mimic language, and to express thoughts 
by the same means. It is ordinarily divided into two forms : motor 
aphasia, or the inability to innervate the motor apparatus for speech, 
while the sensory or perceptive functions are intact ; and sensory 
aphasia, or the inability to recall or understand words, although the 
ability to produce sound is preserved. A variety of other forms, how- 
ever, have in the course of time come to be recognized. Oppenheim 
recognizes the following five varieties : (1) Motor aphasia. This consists 
of the loss of power to speak, with persistence of the understanding of 
spoken, written, and mimic speech. This is the first form of aphasia in 
which it was possible to locate with accuracy the portion of the brain 
involved. The lesion is cortical or subcortical, and involves the foot of 
the third frontal convolution on the left side. The symptoms are 
variable according to the extent and destructiveness of the lesion. (2) 
Sensory aphasia. The perception of sound as such is preserved, but there 
is inability to recognize the significance of words, although spontaneous 
and occasionally voluntary speech is preserved. The lesion is usually 
found in the auditory centre — that is, the first temporal convolution 
on the left side. The symptoms may be variable, alexia being often 
present. (3) Pure alexia, or word blindness. In this, although sight 
is preserved and objects may be recognized, the ability to understand 
written or printed language is lost. Spoken speech is still understood, 
voluntary speech and writing possible, and occasionally written words 
may be read if the patient is permitted to trace the letters with a pencil 
or the finger, recognizing each one as it is formed. The lesion is 
usually found in the left occipital lobe on the external surface, but 
sometimes involves the gyrus angularis. (4) Pure agraphia, or the 
loss of power to write, all the other qualities remaining normal. Lesions 
have been found in the left upper parietal lobe. (5) Optic aphasia. 
In this objects may be seen and recognized, but it is impossible for the 
patient to find the proper name for them. If the objects are recog- 
nized by some other sense, as, for example, hearing or touch, the name 
may be recollected instantly. The lesion is usually found at the junc- 
tion of the first temporo-sphenoidal and the occipital lobes. This form 
is frequently a symptom in otitic abscess. Loss of the stereognostic 
sense may also be regarded in some respects as an aphatic manifestation. 

In order to explain aphasia, it has been customary, since the time 
of Wernicke, to employ the diagram given in Fig. 236. In this the 
triangle, A C M, represents the intra-cerebral paths and centres for 
the mechanism of speech, and the lines Aa and Mm the peripheral 
apparatus. In this diagram A represents the centre for auditory per- 
ception ; M the centre for the emission of motor impulses ; and Cthe 
concept centre, in which the intellect analyzes the impressions received 



DISEASES OF THE NERVOUS SYSTEM. 



1001 



and from which the directing influence for the choice of language is 
transmitted to the motor centre. Act represents the auditory nerve ; 
Mm, the motor nerves to the pharynx, tongue, and lips. Auditory 
impressions may, therefore, be transmitted along Aa to A, thence 




directly to M, and thence to the larynx. This is the mechanism sup- 
posed to be involved in ordinary mechanical speech — that is to say, 
the mechanical repetition of spoken words. The auditory impressions 
may, however, pass from A to C, there be analyzed or understood, and 
then transmitted to M, either in the same or altered form. This con- 
stitutes the intelligent repetition of spoken speech. If the alteration 
of form is considerable, or if, without immediate auditory impressions, 
impulses are transmitted from C to M, voluntary or intelligent speech 
is said to occur. Although this diagram probably does not accurately 
represent the conditions existing in the brain, it has been found that 
the varieties of aphasia that can be theoretically deduced from it cor- 
respond more or less closely to those that may be recognized in actual 
practice. These varieties are as follows : Destruction of the motor 
centre, M, gives rise to the so-called cortical motor aphasia with the 
following symptoms : Loss of (1) voluntary speech ; (2) repetition ; 
(3) reading aloud ; (4) voluntary writing ; (5) writing from dictation. 
There are preserved (1) the understanding of speech ; (2) the under- 
standing of writing ; (3) the ability to copy writing. Destruction of 
the auditory centre, A, gives rise to cortical sensory aphasia. There 
are lost (1) the understanding of speech ; (2) the understanding of 
writing ; (3) the ability to repeat speech ; (4) the ability to write from 
dictation ; (5) the ability to read aloud. There are preserved (1) vol- 
untary speech ; (2) voluntary writing ; (3) the ability to copy writing. 
A lesion in C would give rise to cortical apperceptive aphasia. The 
symptoms of this form would differ very slightly from those due to 
interruption of the tracts supplying it. The centre is probably com- 
plex and its parts are widely distributed. The speech disturbances of 
general paresis are possibly due to its partial destruction. Lesions of 
the various tracts of fibres connecting the different centres with each 
other or with the periphery also produce symptoms. Lesions between 
A and M produce the symptom known as paraphasia. (1) Voluntary 



1002 SPECIAL DIAGNOSIS. 

speech ; (2) repetition of speech ; (3) the understanding of spoken and 
written language ; and (4) the ability to copy writing are all preserved. 
The only symptom, therefore, of this condition is the misuse or false 
pronunciation of words. Thus, objects may be misnamed, one word 
used in place of another, different syllables of the words misplaced 
(literal paraphasia), or the words jumbled in a sentence (verbal par- 
aphasia). There is usually also paragraphia — that is, a similar dis- 
turbance of written language ; paralexia, manifest when the patient 
attempts to read aloud, and sometimes the symptom known as agram- 
matism — that is, the misuse of cases, moods, or tenses. Paraphasia, 
however, occurs also in certain general diseases of the brain, and is 
practically always present if the intrinsic tracts concerned in speech 
are disturbed. Interruption of the tract uniting C and M causes trans- 
cortical motor aphasia. There are lost (1) voluntary speech and (2) 
voluntary writing. There are preserved (1) the understanding of speech ; 
(2) the understanding of writing ; (3) the ability to copy ; (4) the ability 
to repeat words ; (5) the ability to write from dictation ; (6) the ability 
to read aloud. The most characteristic symptom is the inability of the 
patient to remember words, although he is able to repeat them fluently. 
The interruption between A and C gives rise to transcortical sensory 
aphasia. There are lost (1) the understanding of speech ; (2) the under- 
standing of writing. There are preserved (1) voluntary speech ; (2) 
voluntary writing ; (3) the repetition of speech ; (4) reading aloud ; 
(5) writing from dictation. Both voluntary speech and writing are 
usually affected by the paraphasia common to the interruption of the 
intrinsic tracts. It differs from the preceding form particularly in the 
fact that words spoken upon repetition or written from dictation are 
not in the least understood by the patient. In this form communica- 
tion with the patient, even by gestures, is often impossible. Finally, 
lesions may occur in the tracts uniting the centres concerned in speech 
with the periphery. Lesions in the tract Mm give rise to subcortical 
motor aphasia. There are lost (1) voluntary speech-; (2) repetition of 
speech ; (3) the ability to read aloud. There are preserved (1) the under- 
standing of speech ; (2) the understanding of writing ; (3) the ability 
to copy ; (4) voluntary writing ; and (6) writing from dictation. This 
is, of course, the purest form of motor aphasia. Interruption of the 
tract Aa gives rise to subcortical sensory aphasia. There are lost (1) 
understanding of speech ; (2) the repetition of speech ; (3) the ability 
to write from dictation. There are preserved (1) voluntary speech ; 
(2) voluntary writing ; (3) understanding of writing ; (4) reading aloud ; 
and (5) copying. 

This theoretical classification with groupings of symptoms is sus- 
ceptible to modification in actual pathology by a variety of conditions. 
The most important modification is that produced by the existence of 
possible lesions of other centres concerned in speech. Thus, the share 
taken by the visual receptive and apperceptive centres is of great 
importance in all persons who have been taught to read. They are 
necessarily concerned also in the production of writing. It is not, 
however, possible to represent them by a diagram as we have repre- 
sented auditory and motor speech, for it appears that impulses from 



DISEASES OF THE NERVOUS SYSTEM. 



1003 



the visual centres must pass through the receptive centre for speech, 
or A, before being transferred to the arm centre or the speech centres. 
The same is true for tactile impressions. These are of importance 
chiefly in blind persons who have been taught to read with their 
fingers, in whom, indeed, they may equal in importance the role of 
the visual centres in normal persons. Various complicated diagrams 
have been devised for the purpose of exhibiting the influence of all 
these centres upon speech, and Mills has introduced an additional 
naming centre, situated in the third temporal convolution, in which 



Fig. 237. 




L.P.O.C. 
R.P.O.C. 



R.P.A..C. 

L.P.A.C. 

A, auditory centre (centre for word-hearing) ; V, visual centre (centre for word-seeing) ; N, 
naming centre (centre where percepts are given in name) ; B, motor speech centre in Broca's 
convolution (regarded by Broadbent as a propositionizing centre) ; an utterance centre— motor 
centre— is also required to complete the motor side of the speech process, if the view is accepted ; 
G, graphic centre; R. Oc, primary cortical visual centre in the right occipital lobe; L. Oc, 
primary cortical visual centre in the left occipital lobe; R. P. O. O, optic centres at the base 
of the brain, right side; L. P. O. C, optic centres at the base of the brain, left side; R T., 
primary cortical auditory centres in the right temporal lobe ; L. T , primary cortical auditory 
centres in the left temporal lobe ; R. P. A. C, auditory centres at the base of the brain, right side ; 
L P. A. C, auditory centres at the base of the brain, left side. 

perceptions are given the names that properly belong to them. His 
diagram is one of the most satisfactory of all the more complicated 
diagrams representing the speech function (see Fig. 237), but, unfortu- 
nately, it is not yet possible to deduce from it theoretically the symptoms 
that actually occur. Another source of error is the fact that lesions 
may be only partially destructive, or may be so large as to involve two 
or more tracts or centres at the same time. Under these circumstances 
the symptoms become very complex, and it is often impossible to deter- 
mine the extent of the physiological disturbance that has been pro- 
duced. Usually, however, the localization of these lesions is not dim- 



1004 SPECIAL DIAGNOSIS. 

cult, on account of the predominance of certain characteristic localizing 
symptoms. 

It will be obvious from this description that it is necessary in each 
case of aphasia to test a variety of functions. These can best be 
examined as follows : 1. Voluntary speech. If the patient is able 
to answer questions intelligently or makes spontaneous intelligent 
remarks to the physician, voluntary speech is preserved. Voluntary 
speech may, however, exist and the remarks of the patient be never- 
theless unintelligible when there is an extreme degree of paraphasia. 

2. The ability to repeat words. This may be tested by merely saying 
a word or several words and getting the patient to repeat them. 
Mechanical speech, whose centre is supposed to be located in the 
speech area of the right hemisphere, may also be tested by request- 
ing the patient to repeat some well-known series — such, for example, as 
the names of the days of the week, the alphabet, the numbers, or the 
months. Sometimes familiar songs may be remembered and spoken 
when it is absolutely impossible for the patient to make an intelligent 
answer. Under striking emotional conditions epithets or oaths may 
also be employed. The ability to repeat words may sometimes be 
present when it is impossible to determine it on account of the exist- 
ence of transcortical sensory aphasia. Under these circumstances it is 
impossible to make the patient understand what he is expected to do. 

3. Reading aloud. It must not be forgotten that in some cases this 
symptom is masked by defects of vision. If possible, the eyes should 
always be examined and the patient be given his glasses if he has been 
in the habit of using them. It is advantageous to use large type, such 
as the headlines of newspapers. 4. Voluntary writing. This symptom 
may be masked by the existence of right hemiplegia and inability to 
write Avith the left hand. 5. Writing from dictation. As in the repe- 
tition of speech, this symptom may be masked by the inability of the 
patient to understand what he is expected to do. 6. Copying. Errors 
of vision should again be excluded as well as paralysis and other motor 
disturbances of the arm. 7. The understanding of speech. This is 
perhaps one of the most difficult of all aphatic symptoms to determine. 
The patient is usually requested to perform some simple action, such 
as putting out the tongue, touching the ear with the hand, etc. This 
may be perfectly performed, but more complex commands or long 
statements may not be understood. It is supposed that this is per- 
haps due to incompleteness of the lesion, or to a general disturbance of 
intellect, such as must occur in any case of aphasia, in a more or less 
pronounced degree. It is, therefore, important to attempt if possible 
to converse with the patient, getting him to reply by gestures, or writ- 
ing, according to his ability, and gradually to employ more and more 
complex statements. In cases of marked paraphasia the improper use 
of words in the replies may lead to the belief that the patient does not 
understand what is said to him, when, as a matter of fact, word per- 
ception is perfect. 8. Understanding of writing. This is subject to 
the same errors as the understanding of speech, and, in addition, the 
possibility of visual defect. 9. The existence of paraphasia. This, of 
course, can only be detected when either voluntary speech or the ability 



DISEASES OF THE NERVOUS SYSTEM. 



1005 



to repeat words is present. Under these circumstances it may be recog- 
nized when it is only slight in degree by getting the patient to repeat 
words of many syllables, such as " incomprehensibility/' or sentences 
of several words. Disturbances of writing, apart from disturbances of 
speech, may also occur. These may be better understood by a considera- 
tion of Fig. 238, in which the writing centres are added to the speech 
centres. It will be seen from this that there may be destruction of W, 
or agraphia. There are lost (1) voluntary writing ; (2) copying ; and 
there is preserved the ability to read. Destruction of V, or cortical 
alexia. This is characterized by the loss of (1) the recognition of writ- 
ten words ; (2) voluntary writing. Speech may be intact. Destruction 
of W V, or conduction agraphia. There is lost (1) voluntary writing ; 
(2) voluntary copying. There is preserved ability to read — that is to 
say, it corresponds exactly to the preceding form. Under such circum- 
stances paragraphia may exist in this type. Transcortical agraphia. 




There is lost voluntary writing. There is preserved (1) mechanical 
copying; and (2) reading. Transcortical alexia. There is lost the 
ability to read. There is -preserved (1) voluntary writing ; (2) copy- 
ing. Finally, there may be interruption of the tracts to the periphery, 
giving rise to subcortical agraphia. There are lost (1) voluntary 
writing ; (2) copying. There is preserved reading. Paragraphia 
never occurs in this form. Subcortical alexia. There are lost reading 
and copying. There is preserved voluntary writing. All of these 
forms may coexist with the various types of aphasia. In testing the 
patient for alexia the following symptoms should be examined : (1) 
Voluntary writing (see above) ; (2) writing from dictation (see above) ; 
(3) copying ; and (4) the recognition of letters either spoken or written. 
In testing patients for voluntary writing with the left hand, it must be 
remembered that many aphasics give mirror writing. The following 
terms are also used in connection with aphasia : aphrasia, the inability 



1006 SPECIAL DIAGNOSIS. 

to form sentences with words ; dysphasia, the imperfect formation of 
sentences ; apraxia, the total loss of speech. 

By anarthria is meant a disturbance in the peripheral motor 
mechanism of speech, as a result of disease of the nuclei in the medulla 
or of the peripheral nerves arising from them. This may vary in 
degree from complete aphonia, or loss of power to make sounds and 
words, which occurs in bulbar paralysis, or the aphonia of laryngeal 
paralysis, in which whispering speech is still preserved, to merely the 
imperfect pronunciation of certain consonants, as a result of local paral- 
ysis or paresis of the lips or tongue. Anarthria may be permanent or 
temporary, or, in cases of slight paresis, recurrent, giving rise to inter- 
mittent claudication of speech. It is best tested by directing the patient 
to repeat letters of the alphabet, to count, or to repeat words with long 
syllables and difficult consonants, as "artillery/' -" extraordinarily," 
etc. Allied to anarthria, but perhaps the result of certain functional 
disturbance, are stuttering and stammering. In the former, if the patient 
attempts to speak, there is inhibition of motion for a longer or shorter 
interval, and then the word may be pronounced with explosive violence, 
and the following words of the sentence spoken normally. In stam- 
mering there is frequently repetition of the first two or three consonants 
of the word, particularly if these happen to be labials. Stuttering 
and stammering are sometimes associated with defective intelligence. 
Finally, there are a series of disturbances of speech in which intellec- 
tual derangement is apparently the chief factor. These may perhaps 
be forms of aphasia due to partial destruction of the concept centre or 
centres. Among them may be mentioned the inability or unwillingness 
to speak, that occurs in the mutism of the insane ; a tendency to exces- 
sive speech, logorrhoea ; the omission of syllables, particularly character- 
istic of general paresis ; difficult words, such as those mentioned above, 
being pronounced imperfectly, as " arlry " for " artillery," or even less 
accurately. Scanning speech, in which the words are separated by 
considerable intervals, and are spoken with a peculiar drawl and a 
descending cadence. It is particularly characteristic of multiple scle- 
rosis, but may occasionally occur in general paresis. Other forms are : 
explosive, or staccato speech, and a peculiar, slow, drawling utterance, 
occasionally termed bradylalia, that occurs in certain states of mental 
depression. Echolalia occurs almost exclusively in imbeciles, and is 
characterized by the repetition of all sounds heard. 

Disorders of nutrition, or trophic changes, are lesions pro- 
duced in tissues as a result of defective or altered innervation. They 
may be classified clinically into superficial trophic changes affecting 
the skin and its appendages, etc., and deep trophic changes affecting 
the muscles and joints. Among the superficial trophic changes of the 
mild form may be included vasomotor disturbances. In a strict sense 
flushing and the dead finger of Raynaud's disease are trophic altera- 
tions, but it is not certain what parts of the central nervous system are 
involved in order to bring them about. More severe are the various 
eruptive disorders that occur, particularly a herpetic eruption along 
the course of the nerve {herpes zoster). This occurs chiefly along the 
intercostal nerves, but may also occur along the other nerves of the 



DISEASES OF THE NERVOUS SYSTEM. 1007 

body, such as those of the face. It is characterized by the appearance 
of numerous vesicles surrounded by a congested zone and limited 
strictly to the distribution of the nerve or nerves involved. It occurs 
in neuralgias, in chronic neuritis, and in some cases as a result of an 
injury to the ganglion of the posterior spinal root. Among the milder 
trophic disturbances are the graying or falling out of the hair in the 
distribution of some particular nerve and the alterations in the nails. 
The latter are characterized by an increased brittleness, the formation 
of longitudinal ridges, and an excessive slowness of growth, which may 
be best detected by staining the nail at its root with nitric acid and 
comparing the amount of growth with that observed in a normal nail. 
These trophic disturbances in the nail occur in general cachectic states, 
but they are usually slight. They are more pronounced in lesions of 
the peripheral nerves supplying the fingers and toes, and also occur in 
destructive lesions of the spinal cord in the lumbar or cervical enlarge- 
ment, such as syringomyelia and pachymeningitis cervicalis hyper- 
trophica. More severe lesions are those due to the combination of 
defective resistance and secondary infection. These are chiefly the 
forms of panaritis observed in syringomyelia and characterized by the 
formation of an abscess at the root of the nail, which breaks down, 
leaving a chronic ulcer that heals very slowly, usually with the loss of 
the nail. In leprosy, in either the nodular or neural forms, and in 
Morvan's disease, somewhat similar changes also occur. Atrophy of 
the subcutaneous tissue with loss of elasticity of the skin is also a 
characteristic form of trophic disturbance. The part is shrunken, the 
finger-tips become pointed, the skin is dry and glossy or glazed, and 
the cutaneous bloodvessels, especially the veins, are distended. This 
occurs in destructive lesions of the peripheral nerves, and particularly 
in myelitis or destructive lesions of the spinal cord. An analogous change 
sometimes occurs in the teeth. These either become carious very rapidly 
and are destroyed, or become loosened in their sockets and fall out pain- 
lessly. The latter symptom is characteristic of the early stage of tabes 
dorsalis. There is also a tendency to the formation of chronic ulcers in 
the affected parts as a result of trifling injuries. Finally, severe lesions 
of the central nervous system may give rise to gangrene. This is 
characterized by the rapid destruction of the skin and underlying 
parts in regions subjected to the most trifling injuries, such as pressure. 
The part first becomes red, then a slight abrasion is formed upon the 
surface, followed by ulceration and the conversion of the surrounding 
tissue into a gangrenous mass, black and offensive. The usual situa- 
tion is upon the back, just over the sacrum or to either side of it. It 
is called bed-sore, or decubitus. Bed-sores may also appear upon the 
hips, the knees, the heels, the shoulders, or, hi fact, almost any part of 
the body. They are ordinarily the result of myelitis, in which they 
progress rapidly, and are more extensive than in any other condition. 
They may also occur, however, in cases of profound cachexia or ex- 
haustion, and as a result of prolonged unconsciousness and of lack of 
attention in mental disease. Gangrene of the skin may also occur in 
hysteria. The mechanism of this is not clearly understood, but it is 
supposed to be due to vasomotor disturbances. Other severe cutaneous 



1008 SPECIAL DIAGNOSIS. 

lesions are the deep ulcerations that occur in various parts of the body, 
particularly the feet (mat perforante). These have been noted in tabes 
dorsalis, in syringomyelia, and also in hysteria. Finally, destructive 
lesions of the extremities with loss of the fingers may occur in Raynaud's 
disease, in syringomyelia, and in leprosy. Trophic lesions of the deeper 
parts involve the joints and the muscles. Trophic lesions of the joints, or 
arthropathies, are characterized by the enlargement of the joint involved, 
usually the knee, proliferation of the bone, relaxation of the ligament, 
so that the mobility of the joint is much greater than normal, and, for 
example, in the knee, there may be considerable lateral motion as well 
as flexion and extension. The joint surfaces become rough and give 
rise to a grating upon palpation. Curiously enough, aside from the 
undue mobility, the function of the joint remains relatively good, and 
the patient is often able to walk upon a knee that bends laterally almost 
to a right angle. There is usually little pain. These arthropathies 
may also assume the atrophic instead of the hypertrophic form — the 
arthrite seche of the French. In this case the ends of the long bones 
atrophy and luxation commonly occurs. The frequency with which 
the different joints are affected is, according to Growers, as follows : 
Knee, 45 ; hip, 20 ; shoulder, 1 1 ; tarsus, 8 ; elbow, 5 ; ankle, 4. In 
addition, the fingers and the ends of the ribs may show these altera- 
tions. 

Alteration of the contour of the body occurs, as a whole, in various 
nervous diseases. In acromegaly the bones of the feet, hands, and face 
are greatly enlarged ; there is usually slight kyphosis, and the soft parts 
become thickened, the whole appearance being extremely characteristic. 
In myxoedema the subcutaneous tissues are thickened, giving the subject 
the appearance of enormous obesity. In the various forms of amyotro- 
phy, particularly the spinal type, the patient becomes extremely ema- 
ciated ; alteration of the shape of the head occurs in hydrocephalus, the 
enlargement being globular, and the face, by contrast, very small ; in 
microcephaly the cranium is greatly reduced in size, and the face appears 
more prominent and rather of an animal type. Occasionally, in the 
various chronic lesions associated with idiocy and epilepsy, there may 
be marked asymmetry of the skull. Sometimes an intracranial tumor 
will also produce a local distortion. Alterations in the expression or 
appearance of the face are produced by exophthalmic goitre, which is 
readily recognized, on account of the marked prominence of the eyes 
and the swelling of the neck. In facial tic the lightning-like contrac- 
tions of the muscles on one side of the face, occurring at more or less 
frequent intervals, are extremely characteristic. In facial paralysis in 
the early stage the absence of folds on one side of the face, the droop- 
ing corner of the mouth, and partially opened eyelid are typical of 
the condition. In the later stage contractures may occur, causing the 
mouth to be drawn up and the eye to be kept partially closed with 
accentuation of the normal folds of the skin. Mimic paralysis — that 
is, failure of one side of the face or of both sides to assume an expres- 
sion in accordance with the language or the feelings of the patient — 
occurs in lesions of the optic thalamus, and perhaps as a result of par- 
tial injury to the facial nerve. Stolidity of expression — that is, immo- 



DISEASES OF THE NERVOUS SYSTEM. 1009 

bility of the facial muscles — occurs in paralysis agitans. Finally, in 
various mental diseases the expression of the features may more or less 
closely indicate the type. Thus the mournful countenance of the mel- 
ancholic, the excited, eager aspect of the maniac, or the furtive, anxious 
expression of the paranoiac, have all been described. It must not be 
forgotten, however, that temporary emotional states may give rise to 
the same manifestations. The Mongolian type of the features — that 
is, slightly oblique eyes and high cheek bones — seems to be character- 
istic of a certain form of idiocy. The reason for its occurrence is 
not known. Alterations in the posture of the body occur in a great 
variety of diseases. The spinal column may be permanently bent and 
ankylosed in rhyzomyelic spondylosis. This may also be associated 
with ankylosis of the large joints. The position and gait in every 
case are quite characteristic. Angular deformity of the spine occurs 
in Pott's disease. Lateral curvature frequently ' occurs in the various 
forms of muscular dystrophy and in Friedreich's ataxia. The pres- 
ence of a large, fluctuating tumor at the base of the spinal column over 
the lumbar or sacral region is indicative of spina bifida, the lesion 
being, of course, congenital, and in this case there is often an extensive 
growth of hair upon the skin covering the tumor. 

Changes in the Extremities. Various alterations in the contour of the 
arms are produced by muscular atrophy. The most characteristic is 
the flattening of the shoulder-joint that occurs as a result of the wast- 
ing of the deltoid and the peculiar appearance of the hand produced 
by the wasting of the thenar and hypothenar muscles. In the latter 
the thumb assumes a position parallel to the fingers, which is only 
characteristic, however, when it involves the metacarpal bone as well 
as the phalanges (ape-hand). The position of the hand is affected in 
paralysis of the extensors, giving rise to wrist-drop in injury to the 
radial and to the ulnar nerves. If the latter is involved the interossei 
muscles are paralyzed, so that the proximal phalanges can no longer 
be flexed, and the extensors gradually pull them backward until they 
are perpendicular to the dorsum of the hand (main en griffe). Enlarge- 
ment of the hands, as a whole, occurs in acromegaly and in pulmonary 
osteoarthropathy. Mutilation of the fingers is frequently characteristic 
of syringomyelia, Morvan's disease, Raynaud's disease, and leprosy. 
(See Trophic Changes.) The alterations produced by muscular disease 
in the lower extremities are analogous to those that occur in the upper 
extremities. In addition, however, there is a peculiar alteration pro- 
duced by pseudo-hypertrophic muscular atrophy, in which the limbs 
appear to be of Herculean development. Enlargement of the feet, as 
a whole, occurs in the same conditions as does enlargement of the 
hands. Deformities of the feet are much more common as a result of 
contractures following anterior poliomyelitis, which gives rise to the 
various types of club-foot. Certain nervous diseases frequently cause 
deformity of the knee and hip-joints, particularly syringomyelia, 
which gives rise to a form of dry arthritis of the hip ; and tabes dor- 
salis, producing the tabetic arthropathies. (See Trophic Lesions.) 

Mental Disturbances. These are of most varied kinds. They 
may be divided into disturbance of consciousness and disturbance of 

64 



1010 SPECIAL DIAGNOSIS. 

intellection. Disturbances of consciousness may be of various degrees. 
The mildest form is called apathy. The patient lies quietly, makes no 
voluntary attempt to commence a conversation, shows no interest in his 
surroundings, and only answers if spoken to. A more severe state may 
be spoken of as lethargy or stupor. The term coma implies that it is 
impossible to arouse the patient by any means, and at the same time the 
condition resembles more or less closely actual sleep. The reflexes are 
usually preserved, and there is a certain degree of perception to painful 
impulses, manifested by the withdrawal of the part irritated. Uncon- 
sciousness is, of course, a condition that cannot be sharply differentiated 
from this. The term is ordinarily applied to conditions that do not 
resemble natural sleep. The patient may lie quietly, but the breathing 
is stertorous ; the eyes may be opeu ; all the muscles may be relaxed 
or various types of spasm may be present. These conditions occur in 
the intoxications, infections, poisonings, and as a result of severe injury 
to the head. A peculiar type of coma, known as coma vigil, is charac- 
terized by complete relaxation of the patient, whose eyes, nevertheless, 
remain open and appear to observe that which transpires around the 
bed. The mildest form of disturbance of intellect consists in impair- 
ment of memory, or amnesia. This may be restricted to the memory 
of certain things only, as the names of certain classes of objects or cer- 
tain groups of words. It may also be restricted to loss of memory for 
certain definite periods of time, which may occur as a result of severe 
injury or disease during or about this period. If the memory is lost 
for the period preceding the traumatism, the condition is spoken of 
as antero-active amnesia ; if for the period following, retro-active am- 
nesia. Memory is commonly impaired in old age, and often as a result 
of chronic cerebral disease, particularly in paralytic dementia. General 
impairment of the intellect is spoken of as imbecility or idiocy. In its 
milder forms imbecility consists in diminution of the reasoning powers, 
so that the patient is unable to form accurate judgments. In its severer 
grades, and particularly in the more pronounced forms of idiocy, intel- 
lectual activity may appear to be absolutely abolished, life being merely 
a mechanical process not under control of the reason. Both conditions 
are usually associated with alterations in the substance of the brain, 
either in the form of hydrocephalus or of the various scleroses associ- 
ated with epilepsy. Exaltation of the intellectual functions associated 
with excitement, and more or less violence is usually spoken of as delir- 
ium. This may be severe or mild. It is characterized by a tendency to 
talk or to be noisy, and by great restlessness. Delirium occurs in many 
of the acute infectious diseases, particularly in meningitis. Among the 
commoner symptoms of intellectual disorder usually grouped under 
the term insanity are exaltation, or mania, depression, or melancholia, 
and delusional states, or paranoia. By mania, is meant excessive intel- 
lectual activity, characterized by a tendency to be noisy, to be active, 
fondness for singing, shouting, swearing, or punning. There is usually, 
also, in the acute forms a rapid loss of weight and decrease in the physical 
powers, while the patient believes himself to be in the most admirable 
and exceptional condition. Mania occurs as a nervous disease and as 
the result of inflammations of the brain-substance in acute delirium. 



DISEASES OF THE NERVOUS SYSTEM. 1011 

It occurs in the exacerbations of general paresis and in diseased states 
of unknown etiology that are denominated by the term itself. In 
melancholia the expression of the patient is mournful, he is commonly 
quiet, sits with his head cast down, refuses to speak, to eat, or to take 
any interest in what goes on about him. Often he weeps or groans 
constantly, and when persuaded to talk, expresses an acute sense of his 
manifold sins and the hopelessness of salvation, or will complain of 
misfortunes that have not befallen him. Melancholia occasionally 
occurs in general paresis, particularly in patients whose vitality has 
been exhausted by excesses. It also occurs as one of the varieties of 
insanity. The term paranoia is used by different authors in very dif- 
ferent senses. In general, it may be said that the majority imply by 
it the existence of delusions or false ideas that have, among themselves, 
a certain logical sequence, or, as the term is, are organized. Thus a 
paranoiac may believe that he is being persecuted by a certain person, 
and be able to give reasons why his persecutor should torment him. 
It must not be forgotten that occasionally these delusions may be true 
in fact, although none the less symptoms of the mental condition. 
When there is merely a false idea it is spoken of as a delusion. If 
the person complains of certain physical impressions, such as non-exist- 
ent sounds, visions, odors, or tastes, the term hallucination is generally 
employed. 

Localization of Lesions of the Nervous System. In a diag- 
nosis of diseases of the nervous system, particularly those that are the 
result of focal lesions, it is usually far more important to determine the 
situation of the lesions than the nature of the pathological process. 
The nervous system may be regarded physiologically as a collection of 
neurons. By neuron is meant a nerve-cell and all its processes to their 
ultimate ramifications. The processes are of two kinds : the so-called 
protoplasmic processes, which are relatively short, thick, and branched, 
and appear to resemble in many respects the protoplasm of the nerve- 
cell itself ; and the axis-cylinder, a long, slender process that in its 
course gives off at regular intervals still more slender branches, the 
collaterals, and at its termination usually breaks up into a small tuft of 
fibres that surround some other ganglion cell. An exception to the 
latter rule is formed by the axis-cylinders of the motor cells that run 
to the muscles, and end in tufts of fibres distributed to peculiar 
terminations in the muscle-fibres. The axis-cylinders, at a certain 
distance from the nerve-cell, usually become surrounded by myelin 
sheaths, and constitute the nerve-fibres which make up the greater bulk 
of the central nervous system (the white substance), and practically all of 
the peripheral nervous system. Neurons with similar functions are usu- 
ally grouped together, the aggregation of the cells forming a nucleus, and 
of the fibres a bundle or system. The gray matter is largely composed 
of these groups of ganglion cells or nuclei. Physiology has shown, al- 
though not absolutely conclusively, that the axis-cylinders convey im- 
pulses from the cell, and the protoplasmic processes cpnvey impulses or 
nutriment to the cell. In the cell itself these impulses are modified or 
altered in some as yet unknown manner. At present the course and 
functions of comparatively few of the groups of neurons are known. 



1012 SPECIAL DIAGNOSIS. 

Those that have been most accurately studied may be divided into the 
sensory neurons, conveying impulses from the peripheral nervous sys- 
tem, and the motor neurons, conveying impulses from the central 
nervous system to the muscles. The sensory neurons commence in the 
various sensory corpuscles, in the skin, and organs. They pass through 
the peripheral nervous system to the posterior roots of the spinal cord, 
and here they enter the cells in the ganglia of the posterior roots. 
From these cells a fibre emerges that for a short distance is continuous 
with the entering fibre, and then leaves it and continues along the pos- 
terior root of the spinal cord. Here it divides into two branches, an 
ascending and a descending branch. Of the function of the latter 
nothing certain is known. Some of the ascending branches pass into 
the lateral posterior column (Burdach), and at a higher level into the 
median posterior column (Goll). Those entering the cord in the upper 
dorsal and cervical regions, however, do not pass into the median poste- 
rior column, but continue in the lateral posterior column to a nucleus in 
the medulla. Both columns end respectively in the nucleus cuneatus 
and the nucleus gracilis. These two nuclei may be looked upon as indi- 
cating the termination of the peripheral sensory neurons. These two 
groups of fibres probably convey only touch and muscular sensations. 
The fibres conveying pain and temperature sensations apparently pass 
up the cord through the central gray matter, but their central termi- 
nation is not yet definitely known. From the ganglion cells in the 
two nuclei in the medulla, axis-cylinders arise that pass toward the 
brain and form a mass of fibres known as the filet. In the medulla 
these are situated on either side of the median line, lying between 
the olivary bodies. They continue to occupy the central regions of 
the pons in its posterior part, but anteriorly they gradually spread out 
until they form a narrow band, placed horizontally, just below the 
gray matter surrounding the aqueduct of Sylvius. They then enter 
the tegmentum of the cms, and the majority lose themselves in the 
ventral nucleus of the optic thalamus. They constitute the second 
chain of sensory neurons. It is probable that from the optic thal- 
amus, and from the other nuclei in which perhaps fibres of the filet 
terminate, other axis-cylinders arise which pass through the corona 
radiata to the sensory areas in the cortex. These sensory areas will 
be discussed in connection with the cortical localization. 

Destructive lesions in the peripheral sensory nerves produce total 
anaesthesia of the part supplied. Partial lesions may produce partial 
anaesthesia or even dissociation of sensation. Irritative lesions of the 
peripheral nerves produce severe pain, usually referred to the part sup- 
plied by the nerve, and there are also sensitive points or general tender- 
ness over the nerve trunk. Certain forms of irritative lesion produce 
partial alteration of sensation, which is usually spoken of as pares- 
thesia (q. v.). Trophic changes in the skin often occur. Lesions of 
the posterior roots also produce total anaesthesia. If the lesion is on 
the peripheral side of the ganglion there are in addition trophic changes 
in the part supplied. If the lesion lies between the ganglion and the 
spinal cord, the anaesthesia is total, but trophic changes do not occur. 
Lesion of the ganglion itself usually produces anaesthesia and atrophic 



DISEASES OF THE NERVOUS SYSTEM. 



1013 



changes, if complete ; if partial, the symptoms are variable. In some 
cases herpes zoster along the course of the nerve has been observed. 
Irritative lesions of the posterior roots produce fulgurant pains in the 
limbs, or a feeling of constriction in the trunk. They may also be the 
cause of visceral crises. Destructive lesions of the posterior columns 
of the spinal cord produce more or less tactile anaesthesia and loss of 
the muscle sense. As a result of the latter there is ataxia. Lesions of 
either of the two central sensory neurons produce various forms of anaes- 
thesia, depending upon their extent. According to our knowledge of 



Fig. 239. 




Diagram to show the relative positions of the several motor tracts in their course from the cortex 

to the cms. 
The section through the convolutions is vertical ; that through the internal capsules, I C, hori- 
zontal; that through the crus is again vertical. CN, caudate nucleus; O TH, optic thalamus; 
L2 and L3, the middle and outer parts of the lenticular nucleus ; f a I, face, arm, and leg fibres. 
The words in italics indicate the corresponding cortical centres. (Gowers.) 

this subject, destructive lesions, such as hemorrhage or aneurism in the 
posterior portion of the posterior limb or the internal capsule, or destruc- 
tive lesions of the optic thalamus, are usually associated with hemian- 
esthesia on the opposite side of the body. At times, tactile sense is 
preserved and only the pain sense lost. As a rule, however, all forms 
of sensation are more or less affected. 

The motor neurons consist of two groups, the central and peripheral 
neurons. The central motor neurons commence in the motor portion 
of the cortex. They then pass through the corona radiata to the inter- 
nal capsule, where they form a large band of fibres occupying the knee 



1014 



SPECIAL DIAGNOSIS. 



and the anterior two-thirds of the posterior limb. (See Fig. 239.) 
The fibres for the face occupy the knee and anterior third of this por- 
tion. Next come the fibres for the arm, then those for the leg, and, 
finally, the fibres for the trunk. From the internal capsule the fibres 
pass into the crura cerebri, where they lie beneath the substantia nigra, 
occupying about the middle of each eras. The fibres for the face and 
cranial nerves lie internal to those for the extremities and trunk. 
From here they pass to the ventral portion of the pons, where they are 
broken up into small bundles by the association of fibres of the two 
cerebellar hemispheres. These reunite and form the pyramids in the 
anterior portion of the medulla, which decussate in the first cervical 
segment and pass down the cord as the lateral pyramidal columns. 
(See Fig. 240.) A few of the other fibres, however, do not decussate 



Fig. 240. 





wmmmmrn. 



ROOT. 
Diagram showing the different tracts of the cord. (Goweks.) 



at this time, but pass downward in the direct pyramidal columns, which 
decussate through the anterior commissure of the cord at lower levels. 
The fibres for the cranial nerves decussate, as a rule, in the neighbor- 
hood of the nuclei for these nerves, and by this means we are able to 
locate with considerable accuracy the situation of lesions in the pons 
and medulla. The fibres for the oculomotor nerves decussate in the 
tegmentum and the nuclei around the aqueduct of Sylvius. The fibres 
for the facial decussate in the anterior portion of the pons. From this 
point downward fibres are continually crossing the median raphe to 
the nuclei of the various motor cranial nerves until the main decussa- 
tion — that is, in the first cervical segment. It follows, therefore, that 
if a lesion occurs in such a position that it affects the fibres of one of 
the cranial nerves after they have crossed the median line, at the same 
time involving the undecussated fibres of the pyramids, we will have 
the syndrome known as a crossed paralysis — that is, the muscles sup- 
plied by the affected cranial nerves will be paralyzed on the same side 



DISEASES OF THE NERVOUS SYSTEM. 1015 

as the lesion, and the rest of the body on the opposite side. (See 
Lesions of the Cranial Nerves.) The peripheral motor neurons com- 
mence in the cells of the anterior cornna of the spinal cord, passing out 
through the anterior roots, and reach the muscles through the periph- 
eral nerves. 

The functions of these two neurons are apparently not identical. 
The central motor neurons convey impulses from the cortex to the 
cells of the anterior cornua, by which the latter are stimulated to pro- 
duce muscular movement. At the same time they seem to possess an 
inhibitory influence by means of some form of constant activity, so 
that while they are intact the reflexes are restrained, and the muscles 
do not become spastic. Upon the nutrition of the muscles they appar- 
ently have no influence whatever, or at least act only indirectly by 
causing paralysis. The peripheral motor neurons control directly mus- 
cular activity. By their continuous action they maintain muscle tonus, 
and when unrestrained by the influence of the upper neurons produce a 
condition of spasticity. While they and the sensory neurons forming 
the arc are intact, reflex action persists. They also control in some 
mysterious way the nutritional changes in the muscles. Destructive 
lesions of the lower neurons — that is, of the peripheral nerves involving 
the motor fibres of the anterior root and of the ganglion cells in the 
cornua — cause paralysis and degenerative changes in the muscles. Irri- 
tative lesions cause spasms ; these are usually tonic in character, and 
either momentary (as in facial tic) or more rarely persistent (tetanic). 
The muscle tonus is lost, and, therefore, the paralysis is flaccid in char- 
acter and the reflexes are abolished. Destructive lesions in the central 
motor neurons, on the other hand, produce paralysis of the muscles. 
but their nutrition is not impaired, their muscle tonus is increased 
until they become spastic, and the reflexes are exaggerated. Irritative 
lesions of the central nervous neurons produce, as a rule, clonic spasms. 
These may be limited to the part irritated, as occurs in some form of 
central softening in the motor region, or become generalized. (See 
Convulsions). 

Cortical Localization. The origins of the motor neurons and the 
terminations of the sensory neurons are, as will be seen from this descrip- 
tion, in the cortex of the brain. It is, therefore, of considerable im- 
portance to be able to locate the portions of the cortex that have to 
do with these functions. As a result of experimental work and of the 
repeated examination of pathological specimens, a considerable amount 
of knowledge has been acquired upon this subject. The motor regions, 
indeed, are marked out with accuracy, and some of the regions for the 
reception of impulses from the organs of special sense are also certainly 
known. The cortex of the brain has been divided into various regions 
that are referred to certain fissures that are quite constant in position. 
The most important of these is the fissure of Sylvius. It separates 
the temporo sphenoidal lobe below from the frontal and parietal lobes 
above. Around its posterior extremity there winds the convolution 
known as the gyrus angularis. Next is the Rolandic fissure, passing 
from the superior longitudinal fissure to the fissure of Sylvius, with 
which it forms an acute angle. It separates the frontal from the pari- 



1016 



SPECIAL DIAGNOSIS. 



etal lobe, and lies in the midst of the motor region of the cortex. In 
front of it is the ascending frontal convolution, and behind the ascend- 
ing parietal convolution. These two contain nearly all the motor 
centres. The third prominent fissure is the occipito-parietal. It is 

Fig. 241. 

Ml ° T o „ 




Cortical centres and areas of representation on the lateral aspect of the hemicerebrum. (Mills.) 




Cortical centres and areas of representation on the mesial aspect of the hemicerebrum. (Mills.) 



DISEASES OF THE NERVOUS SYSTEM. 1017 

best defined on the median surface of the brain, but can be traced for a 
short distance on the convex surface. It separates the parietal from 
the occipital lobe. On the median surface it unites at an acute angle 
with the calcarine fissure, the two enclosing between them the trian- 
gular convolution that is known as the cuneus. (See Fig. 241 and Fig. 
242.) The motor centres are so arranged that those for the face are 
in the lowest portion of the motor region, those for the arms just above 
them, those for the legs around these, and those for the trunk in the 
posterior termination of the ascending parietal convolution, along the 
margin of the superior longitudinal fissure. These centres do not repre- 
sent particular muscles, but particular forms of movement, involving 
frequently the simultaneous contraction of several muscular groups. 
It is not known how sharp their limitations are, but it is supposed that 
the central portion of the focus is most exclusively devoted to its func- 
tion, while at the periphery this fades gradually into the surrounding 
centres. The motor region for speech was first discovered by Broca, in 
1861. It occupies the posterior portion of the third frontal convolu- 
tion and the lower part of the ascending frontal convolution. The 
termination of the sensory neurous is not yet conclusively determined. 
It seems likely that some of them terminate in the motor region, and 
others in the upper portion of the parietal lobe. It is probable that 
different forms of sensation are represented by different areas upon 
the cortex, but at present our knowledge of this subject is uncertain. 
The stereognostic sense appears to be situated in the parietal lobe — 
that is, lesions in this locality will cause its loss without disturbance 
of tactile sensation. As it has been shown that this sense is largely 
dependent upon muscular and localization senses, it is likely that the 
fibres concerning these terminate in the parietal lobe. It is to be noted 
that although it is the general rule that fibres from one hemisphere 
ultimately pass to the opposite side of the body, this is by no means 
invariably the case. Certain muscles, such as those of the trunk, appar- 
ently are innervated from both sides of the brain — that is, bilaterally 
— so that if one centre is destroyed the other assumes its functions, 
and no paralysis ensues. It also appears possible, in certain instances, 
for the centre of one hemisphere gradually to learn to perform the 
functions of the centre of the other hemisphere when the latter has 
been destroyed. This is seen most clearly in cases of the destruction 
of the speech centre on the left side, when, if the patient is still young, 
the speech centre on the right side may assume all its duties. 

The Centres for Reception of Special Senses. The cuneus of the 
median surface of the occipital lobe appears to receive directly the 
fibres from the optic tract. When it is destroyed there is bilateral 
contralateral hemianopsia. The pupillary reflexes are, however, pre- 
served, so that light impulses must exert some activity at a point in 
the chain of neurons between this and the eye, probably in the anterior 
quadrigeminal bodies. The centre for audition is situated in the teni- 
poro-sphenoidal convolution. Destructive lesions produce deafness in 
the ear of the opposite side, or at least impairment of hearing, which, 
as a rule, rapidly disappears. The centres for smell and taste have 
been placed respectively in the uncinate and fornicate convolutions. 



1018 SPECIAL DIAGNOSIS. 

The evidence for these localizations is very strong, but is not yet abso- 
lutely conclusive. It is doubtful whether irritative lesions in any of 
the centres for special sense are responsible for hallucinations. 

The functions of the frontal lobes are not well known. It has been 
supposed that they are the seat of intelligence, but there has never 
been adequate proof of this belief. Lesions of the frontal lobes may, 
therefore, exist without giving rise to any symptoms that lead to a sus- 
picion of their presence. On the other hand, the patients may exhibit 
various intellectual disturbances, but, on the whole, none that are char- 
acteristic, and perhaps these symptoms do not occur more frequently as 
a result of disease of this part than when some other part of the brain 
has been affected. It has been claimed that there is a certain degree 
of intellectual impairment ; that the patient, while not insane or even 
eccentric, becomes incapable of exercising the same degree of judgment 
and comprehension that he formerly possessed. It has been claimed, also, 
that a peculiar form of insanity, characterized by progressive dementia 
associated with a manifestation of self-contentedness, occurs only in 
lesions of this part, and it has been given the term moria. The pro- 
duction of a tendency to make puns has also been described to lesions 
in this region. It does not always occur, but, on the other hand, it 
may occur as an early manifestation of insanity without gross lesion 
or in connection with the lesions of other parts of the brain. The 
most important symptoms, of course, are those due to the involvement 
of the adjacent motor centres. The one most frequently affected is the 
speech centre in the third frontal gyri, and as a result aphasia is a com- 
mon associated symptom, particularly if the lesion is situated in the left 
hemisphere. The other motor centres may, however, be involved and 
produce characteristic symptoms. 

The functions of the basal ganglia of the brain are as yet insufficiently 
known to enable us to diagnose lesions situated in them with certainty. 
Lesions in the lenticular nucleus may be entirely latent. In some cases 
they appear to have produced sensory disturbances, but even this is 
doubtful. Ordinarily, the only symptoms they produce are those 
resulting from pressure upon the surrounding parts, such as the inter- 
nal capsule. The optic thalamus appears to receive fibres from many 
parts of the cortex. Its relation to the fillet has already been men- 
tioned, and lesions in this region frequently produce sensory disturb- 
ances. The pulvinar appears to be one of the three basal ganglia asso- 
ciated with the optic tract, and when it is destroyed there is usually 
bilateral contralateral hemianopsia. There is some doubt, however, 
whether this is not due to the involvement of the neighboring struc- 
tures, either the fibres of the optic tract passing just beneath it or of 
the geniculate bodies. Nothnagel and v. Bechterew have called atten- 
tion to the fact that certain localized movements on the part of the 
muscles of the face, particularly those concerned in the expression of 
the emotions, are more or less completely abolished by destruction of 
the optic thalami. The existence of this mimic paralysis has. in a few 
cases, led to the correct diagnosis of thalamic lesion. The anterior 
corpora quadrigemina apparently form one of the intermediate stations 
for the optic tract, the fibres from the nerve ending in them, and new 



DISEASES OF THE NERVOUS SYSTEM. 



1019 



neurons commencing that possibly form the fibres of the optic radiation' 
They are apparently the situations in which the arch of the pupillary 
reflex is completed. The internal geniculate ganglia and the posterior 
corpora quaclrigemina appear to be associated with hearing. 

Lesions in the pons and medulla produce, as a rule, characteristic 
symptoms that make it possible to locate them with considerable accu- 
racy. This is due to the fact that the nuclei of the cranial nerves are 
situated in these two portions of the brain, and also that they form the 
great source of communication between the cerebrum and the spinal 
cord, containing both motor and sensory fibres. (See Fig. 243.) The 
nucleus of the oculomotor nerve is found surrounding the anterior 
portion of the aqueduct of Sylvius, just beneath the anterior corpora 
quadrigernina. Numerous groups of cells have been separated which 
are supposed to belong each to a different muscle. Destructive lesions 
cause partial or complete ophthalmoplegia, according to the extent of 
the lesion. There is, therefore, abolition of the pupillary reflex. Just 



Fig. 24c 




Relative location of the nuclei of the different cranial nerves. (Edinger.) 



behind it, and beneath the posterior corpora, is a small group of cells 
for the pathetic nerve. The nucleus of the trigeminus is situated in 
the anterior portion of the pons, just to the outer side of the fillet, the 
motor group of cells lying inside the sensory group. The Gasserian 
ganglion receives the peripheral branches of this nerve and corresponds 
to the spinal ganglia. In addition the nerve receives a bundle of fibres 
from the lower portion of the medulla. Disturbances of the nucleus 
produce anaesthesia on the same side of the face, involving the conjunc- 
tiva and the mucous membrane of the mouth. There is loss of taste in 
the anterior two-thirds of the tongue, and there is some disturbance of 
smell in the nostril on the same side. At the same time the pterygoid 
muscles are paralyzed and mastication is imperfect. Irritative lesions 
cause tic douloureux. This may also be the result of disease of the 
ganglion. The nucleus of the abdueens lies in the posterior portion of 
the pons, just beneath the floor of the fourth ventricle. Destructive 
lesions cause internal strabismus. The nucleus of the facial nerve is 



1020 SPECIAL DIAGNOSIS. 

found in the posterior portion of the pons, lying slightly behind and to 
the median side of the nuclei for the trigeminus. The fibres from this 
nerve pass out first forward, then downward and backward, and arise 
from the lateral surface of the medulla at its anterior extremity, pass- 
ing forward over the pontine cerebellar tubercles. Destructive lesions 
cause paralysis of the same side of the face, usually involving the upper 
branch. (See Hemiplegia.) Irritative lesions cause facial tic. The 
nucleus of the acusticus is found in the anterior portion of the medulla 
oblongata, just beneath the floor of the fourth ventricle, lying just above 
the superior olivary body. Lesions produce nerve or mental deafness 
on the same side. The nuclei of the vagus and the glosso-pharyngeal 
nerves are apparently in the jugular and petrosal ganglia — that is to 
say, they are sensory nerves, and correspond to the sensory fibres enter- 
ing the spinal cord. From these ganglia fibres pass into the medulla 
oblongata at its lateral aspect, and end in a nucleus in the floor of the 
fourth ventricle. The motor nucleus of the vagus is supposed to be 
the nucleus ambiguus, situated just posteriorly to the olive in the poste- 
rior portion of the floor of the fourth ventricle. Close to the median 
line is the hypoglossal nucleus. Its destruction produces paralysis and 
degenerative atrophy of the corresponding side of the tongue. 

The functions of the pons are merely those of the centres and tracts 
it contains, and therefore the symptoms are dependent upon the situ- 
ation and greater or less amount of destruction that the lesions produce. 
On account of the decussation of the central fibres for the facial nerve 
in this region, crossed paralysis is usually considered pathognomonic of 
pontine disease. The functions of the medulla are also largely dependent 
upon the nuclei and tracts it contains. As it contains the centres for 
the pneumogastric and some of the centres or tracts of fibres for respi- 
ration, lesions in it are ordinarily followed very promptly by death. 
Lesions of the restiform bodies — that is, the lower portion of the medul- 
lary peduncle to the cerebellum — are frequently associated with nystag- 
mus, and may cause the symptoms of cerebellar ataxia. As the medulla 
contains the nuclei of the motor nerves to the pharynx, larynx and 
mouth, paralysis of the muscles in this region is spoken of as bulbar 
palsy. 

The cerebellum is supposed to be concerned in co-ordination and 
the maintenance of the equilibrium. The hemispheres may, however, 
be extensively diseased without giving rise to any symptoms. If the 
middle lobe is affected the characteristic manifestations are disturbance 
of equilibrium and inco-ordination. The gait resembles that of a 
drunken man, nystagmus is frequent, especially in cases of tumor. 
Giddiness and vomiting sometimes occur, but are, however, of no 
localizing value. The knee-jerk is often absent, but sometimes in- 
creased and sometimes variable. If the pyramidal tracts are pressed 
upon it is always increased, and there is then weakness in the extremi- 
ties. As a result of pressure there may be paralysis of the cranial 
nerves, difficulty in articulation, and occasionally epileptiform convul- 
sions. If the medullary peduncle is affected by an irritative lesion, 
quite characteristic symptoms result. These are forced movements — 
that is to say, the patient may have an irresistible tendency to fall 



DISEASES OF THE NERVOUS SYSTEM. 1021 

toward or lie upon one side. There are no symptoms diagnostic of 
disease of the superior or middle peduncles. Disease of one side of 
the pons may cause symptoms similar to those of cerebellar trouble. 

Localization of Spinal Lesions. The spinal cord may be re- 
garded in two ways : First, as the pathway between the peripheral 
nervous system and the brain, containing the tracts running from the 
brain to the motor nerves, and from the sensory nerves to the brain ; 
second, as a number of groups of ganglion cells arranged in horizontal 
layers or segments. These segments are usually classified according 
to the nerve-roots that spring from them. There are, therefore, eight 
cervical, twelve dorsal, five lumbar, and five sacral segments of the 
cord. The white matter of the spinal cord is divided into two regions : 
the antero-lateral part, extending from the median fissure to the poste- 
rior horns, and the posterior part, lying between the posterior horns. 
The antero-lateral part contains the motor fibres or pyramidal tracts, 
whose functions have already been described. In addition, there are 
certain fibres that pass downward whose functions are not certainly 
known. The gray matter of the cord is divided into the anterior and 
the posterior horns. It is composed of nerve-cells and nerve-fibres. 
The nerve-cells in the anterior horns form a large group, which send 
their axis-cylinders into the anterior roots, and comprise the peripheral 
motor neurons. In the posterior horns, in the dorsal region, there is a 
group of cells on the inner side known as the column of Clarke, which 
apparently have something to do with equilibration. Other cells, whose 
functions are not definitely known, are also found in the posterior 
cornua. The gray matter also contains a large number of nerve-fibres, 
some of which pass transversely and apparently are concerned in reflex 
action ; others ascend, and convey to the brain the sensations of pain, 
heat and cold. Each segment of the cord innervates and receives sen- 
sory impressions from an approximately corresponding segment of the 
body, and contains the lower reflex arcs. The motor and reflex func- 
tions of the various segments are shown in the table and the sensory 
functions in Fig. 244 and Fig. 245. 



1022 



SPECIAL DIAGNOSIS. 



Table of Motor and Reflex Functions of the Segment of the 
Spjnal Cord. Modified from Gowers and Muller. 



Segments. 
C. 



Motor innervation. 



1 \ Small rotators of head 

2 J Depressors of hyoid 



3 1 Diaphragm 

4 J Platysma (?) 



Scaleni. 

Lev. ang. scapulas. 

Cucullaris. 



5 1 Deltoid 

| Biceps 

I Coraco brachialis 
* }• Supinator longus 
Spinati 
| Serratus major 

6 J Pectoral major (clav.) ] Pronators 
Triceps 

7 "] Flexors of wrist and 

fingers 
I Pectoralis (costal) 

Subscapularis 
I Latissimus dorsi 

8 J Teres major 



j Extensors of wrist 
J and fingers 



D. 

1 

2] 

3 

4 



6 }■ Intercostal muscles 



1 Muscles of hand "] 

I I 

\- Extensors of thumb }■ 



9 
10 J 
11 
12 



Abdominal muscles 



Erectors of spine 



Quadratus lumborum J 

lleo psoas 

Cremaster 

Sartorius 

Pectineus 

Adductors 

Quadriceps ] 

Gracilis | r^ , -, 

Obturator Gluteal 

Adductors J 

Flexors of knee 



J 1 



Reflex centres. 



I 

J J 



] Dilatation of the pupil, 
sensory part. ( ? ) 

Scapular. 



Tendon reflexes of the 
muscles of the arms. 



Dilatation of pupil, 
motor part. (?) 



I 1 



Epigastric. 



Abdominal. 



Cremasteric. 



}■ Knee-jerk. 

I 1 



Gluteal reflex. 



SJ 



External rotators of thigh 
Extensors of foot 
Tibialis anticus 
Peroneal muscles 

Perineal and anal muscles 



Achillis tendon reflex. 
Plantar reflex. 



Centres for the bladder 
and rectum. 



DISEASES OF THE NERVOUS SYSTEM. 

Fig. 244. Fig. 245. 



1023 








(From Oppenheim. 



(From Oppenheim.) 



General Symptomatology of Lesions of the Brain. Lesions 
of the brain may be irritative or destructive. The former, if affecting 
the motor tract, produce clonic spasms. If destructive, they produce 
paralysis without atrophy, and cause increase in the muscle-tone by 
the removal of the influence of the superior arc and exaggeration of 
the reflexes. All these changes occur in the muscles of the opposite 
side of the body. Irritative lesions are most likely to be extra-cerebral 
— that is, pressing upon the cortex. Lesions in the brain-substance are 
usually destructive, and, therefore, cause paralysis. As motor fibres 
are distributed over a considerable area of the cortex, lesions in this 
region, if circumscribed, are likely to cause monoplegia. If involving 
the area for the face, the upper branch of the facial nerve, which is 
innervated from both sides, is rarely involved. Aphasia only occurs 
if the left side is destroved. Lesions in the corona radiata near the 



1024 SPECIAL DIAGNOSIS. 

cortex usually cause monoplegia ; if near the internal capsule, hemi- 
plegia is more common. Lesions in the internal capsule almost invari- 
ably cause hemiplegia. If the knee and anterior portion of the posterior 
limb are involved, hemiplegia without sensory changes results. If 
they also affect the posterior third of the posterior limb, sensory dis- 
turbances are present, and there is likely to be hemianopsia. Lesions 
in the anterior portion of the anterior limb produce no recognizable 
symptoms, and are termed latent. General disturbances of the brain may 
be caused by increase of the intracranial pressure. This may be brought 
about by growths, traumatism, oedema, or inflammation. There is usually 
headache, delirium or coma, and vomiting. If the process is of slow 
development, a certain amount of adaptation may occur, and only the 
headache and vomiting may be present. The former is occasionally 
sharply localized. In addition, if the pressure be long continued, there 
is oedema of the optic nerve. (See Disorders of the Special Senses.) 

General Symptoms of Disease of the Spinal Cord. These 
depend upon the segment of the cord and upon the nerve-tracts in- 
volved. Lesions are spoken of as transverse if they involve the whole 
cord, unilateral if they involve but one side, and focal if they involve 
only a circumscribed portion. Transverse lesions may be produced by 
inflammation, by pressure either by a tumor or as a result of deformity 
of the vertebral column (Pott's disease). Transverse lesions above 
the fifth cervical segment usually cause death by paralysis of the 
diaphragm. If the patient survive there is paralysis of all four 
extremities and total anaesthesia of the body. There is also paralysis 
of the bladder and rectum and abolition of the cutaneous reflexes, and, 
in* the majority of cases, of the tendon reflexes. Transverse lesions 
between the fifth cervical and the first dorsal segments produce atrophy 
and degeneration of certain muscles of the arm, according to their 
situation. There is spastic paralysis of the legs and total anaesthesia 
of the body as far up as the part that transmits sensation to the lowest 
intact segment. There is paralysis of the bladder and rectum, aboli- 
tion of the reflexes whose arcs are found in the segments involved, and 
sometimes exaggeration of all the tendon reflexes that are completed in 
the lower segments. The cutaneous reflexes are abolished. Lesions of 
the dorsal region produce spastic paraplegia and paralysis of the bladder 
and rectum. The arms escape entirely, and respiration is not disturbed. 
The anaesthesia extends up to the segment involved. Lesions in the 
lumbar region produce atrophy and degeneration of certain groups of 
muscles in the legs, with paralysis and disturbances of sensation, dis- 
tributed according to their extent. The situation of a lesion may be 
roughly determined by a study of the reflexes. If the lesion involve 
the segments concerned in any of these, they are, of course, abolished. 
If the lesion is above them, they are sometimes exaggerated ; if below 
them, they are ordinarily not involved. Lesions of the conus termin- 
alis and the cauda, as they involve the large number of nerve-roots, 
produce a complexity of symptoms. There are irregular areas of 
anaesthesia corresponding to the posterior roots involved, and atrophy 
and degeneration of the muscles supplied by the anterior roots. The 
bladder and rectum usually are affected. 



DISEASES OF THE NERVOUS SYSTEM. 1025 

Unilateral Lesion of the Spinal Cord (the syndrome of Brown-Sequard). 
This produces paralysis of the same side and anaesthesia of the oppo- 
site side, both symptoms extending as far upward as the region sup- 
plied by the segment that has been affected. Disturbance of sensation 
is not total. There is tactile anaesthesia, analgesia, and loss of tem- 
perature-sense on the side opposite the lesion, but persistence of the 
muscular sense, which, however, is diminished or lost on the same side 
as the lesion. Disturbance of motion is complete. Atrophy and de- 
generation occur in the muscles supplied by the involved segment ; 
below this there is spastic paralysis, with increase in the reflexes. 
Above the paralytic area there is a zone of hyperesthesia that has 
never been satisfactorily explained. The commonest cause of unilat- 
eral lesion is traumatism, particularly bullet and stab Avounds. Occa- 
sionally the symptoms develop in the early stages of syringomyelia or 
as a result of tumor or hemorrhage of the spinal cord. Focal lesions 
in the spinal cord produce various symptoms, according to their situa- 
tion. Inflammations involving the gray matter are commonly spoken 
of as poliomyelitis. They usually attack the anterior cornua and in- 
volve only the peripheral motor neuron — that is, they produce paralysis, 
atrophy, and degeneration of the muscles. Inflammatory lesions in the 
white matter are spoken of as leukomyelitis. They produce symptoms 
according to the tracts they involve. 

The Cranial Nerves. The olfactory, optic, oculomotor, pathetic, 
abducens, auditory, and glosso-pharyngeal have already been described 
in connection with the special senses. The trigeminal nerve takes its 
origin from the centres in the pons and medulla already described. 
Destructive lesions of the motor portion cause paralysis of the ptery- 
goid muscles. If they are unilateral it is impossible for the patient 
to move the mouth toward the opposite side when the lower jaw is pro- 
truded. It is to be assumed that atrophy and degeneration of these 
muscles occur, but their electrical examination is practically impossible. 
Irritative lesions produce cramp known as trismus. This is, of course, 
usually due to central disease. The sensory portion of the trigeminus 
supplies the skin of the face and the mucous membranes of the cavities 
of the head. The distribution of the three branches is shown in Fig. 
246. Irritative lesions produce tic douloureux ; destructive lesions, 
anaesthesia in the distribution of the part affected. The facial nerve 
arises from the nuclei in the posterior portion of the pons. These are 
probably double, each supplying a separate branch of the nerve, and 
the superior nucleus is innervated from both sides of the cerebrum. It 
is the motor nerve for the muscles of the face, and supplies the tem- 
poral, masseter, the orbicularis palpebrarum, the muscles of the lower 
part of the face, the muscles of the palate, and the platysma myoides. 
Unilateral destructive lesions produce paralysis of the muscles of the 
face (BelPs palsy). This can be recognized by the disappearance of 
the folds, drooping of the corner of the mouth, and the inability to 
close the eye. In addition there may be loss of taste and hyperacusis 
in the ear on the same side. Occasionally there is deviation of the 
tongue, the palate is oblique, and the uvula is pulled toward the sound 

65 



1026 SPECIAL DIAGNOSIS. 

side. If the peripheral portion of the nerve is involved, usually both 
the upper and lower branches are affected, and the paralysis is general. 
If the lesion is central the upper branch commonly escapes, or, at least, 
instead of being paralyzed, is only paretic. Moreover, in central lesions 
lying above the pons the opposite side of the bod} r is paralyzed. Secre- 
tion of saliva on the same side is diminished or abolished. This may 
be tested on the sublingual glands by raising the tip of the tongue, 
carefully drying the sublingual space and getting the patient to inhale 
some pungent substance, such as acetic acid or musk. The saliva will 
immediately appear on the sound side, but will fail to appear on the 
other. In facial paralysis it is impossible for the patient to masticate 
on the diseased side, because the food collects between the cheek and 
the gums. It is also impossible for him to whistle. Saliva freely 
dribbles from the drooping corner of the mouth, and as it is impossible 
to contract the orbicularis palpebrarum the eye remains open even in 
sleep (lagophthalmus), and the corneal reflex is abolished or imperfect. 
When the patient attempts to close the eye the ball rolls upward and 
outward. In addition, the palatine reflex also disappears. In facial 
paralysis of long standing contractures may occur. In all cases the 
muscles show either partial or complete reactions of degeneration. Irri- 
tative lesions of the facial nerve cause spasm of the facial muscles, 
usually spoken of as facial tic. The vagus nerve supplies motor fibres 
to the larynx, sensory fibres to the lungs, and inhibitory fibres, prob- 
ably sensory in nature, to the heart. It also probably sends sensory 
fibres to the gastro-intestinal tract. Destructive lesions of the vagus 
produce, if unilateral, unilateral paralysis of the vocal cords, interference 
with deglutition, and transient tachycardia. The laryngeal changes 
are most characteristic. (See Chapter I., Part II.) Irritative lesions 
produce spasm of the glottis, with dyspnoea or aphonia. The spinal 
accessory nerve is the motor nerve for the trapezius and part of the 
sternocleidomastoid. Destructive lesions of this nerve are the chief 
cause of torticollis. The hypoglossal nerve is the motor nerve for the 
tongue, and is, therefore, concerned in chewing, swallowing, and speak- 
ing. Unilateral destructive lesions produce paralysis of one-half of the 
tongue, which is protruded toward the paralyzed side, with atrophy and 
degeneration of the muscle. Fibrillary twitchings are usually present. 
The functional disturbance, however, is slight, and the patient may 
complain of no discomfort. Bilateral paralysis produces, however, very 
severe symptoms. The tongue lies flaccid in the mouth, it is impossible 
to protrude it, or even to move it from side to side. Mastication is 
impossible and swallowing exceedingly difficult. Speech is at first seri- 
ously affected, but, as a rule, the patient in time learns to compensate 
the lingual palsy. Paralysis of the tongue as a result of central lesion 
almost never occurs. 

General Diagnosis of Nervous Diseases. It is necessary to 
study the patient according to some fixed plan, otherwise its com- 
plexity and the numerous investigations that it is necessary to make 
render a thorough examination almost impossible. It is true, of course, 
that in actual clinical practice diseases will be met whose clinical symp- 
toms are so characteristic that the diagnosis can be made almost by 






DISEASES OF THE NERVOUS SYSTEM. 1027 

inspection alone, and a prolonged examination will only be useful for 
the purpose of excluding or detecting possible complications. On the 
other hand, certain cases will occur that almost defy diagnosis, on account 
of the multiplicity and contradictory character of the symptoms. In gen- 
eral it may be said that, aside from the history and the subjective symp- 
toms, the physician will meet with four groups of signs : disturbance 
of sensation, disturbances of motility, atrophic and degenerative lesions, 
and disturbances of intelligence. These should be taken up in the fol- 
lowing order : 1. Disturbance of intellect. Tt is often possible to detect 
this, when it exists, by simple conversation with the patient. It may 
be indicated by the history, or, on the other hand, the history and the 
behavior of the patient may exclude it altogether. 2. Disturbances of 
motion. It is well to study first the more patent alterations. Thus the 
patient should be told to move the arms and legs, in order to detect 
paralysis ; he should be requested to walk, in order to study the gait ; 
he should be directed to perform some fine, co-ordinated movement, in 
order to detect possible ataxia ; and to put the muscles in a state of 
tension, in order to exaggerate a possible tremor. Following this the 
individual movements should be carefully examined. It must be 
remembered that, whether the lesion is in the central or peripheral 
nervous system, disturbance of motility is manifested only in the 
muscles themselves, and the investigations, therefore, should commence 
with these — that is to say, it is not desirable to test the motor functions 
of each particular nerve, but rather of each particular group of muscles, 
and to deduce from the changes found in them the nerve or segment 
involved. I'he following table from Sahli gives a classification of the 
muscles of the extremities, according to their functions, with their 
nerve-supply : 

Table of the Voluntary Muscles Grouped According to their 
Functions, with their Nervous Supply. (From Sahli.) 

Upper Extremity. 
A. Movements of the shoulder-blade. 

1 . Elevators of the shoulder. 

Middle part of the cucullaris (N. accessorius). 
Ehomboidei (N. dors, scapul., 5th cervical nerve). 
Levator scapulae (2d and 3d cerv. nerv. and N. dors. scap. ). 
Upper portion of the pectoral major (Nn. thorac. ant., 5th and 6th cerv. 
nerves). 

2. Depressors of the shoulder. 

Pectoralis minor (Nn. thorac. anterior). 

Lower portion of the latissimus dorsi (N. subscapularis). 

Lower portion of the pectoralis major (N. thorac. ant.). 

3. Adduction of the shoulder. 

Lower portion of the cucullaris (N. accessor. ). 

Upper portion of the latissimus dorsi (N. subscapulars) . 

4. Abduction of the shoulder. 

Upper third of the pectoral, major (N. thor. ant.). 

Serratus anticus major (N. thorac. longus, 6th, 7th, 8th cerv. nerv.). 



1028 SPECIAL DIAGNOSIS 

B. Movements of the shoulder-joint. 

1 . Elevators of the arm. 

(a) Laterally, deltoid (N. axillaris). 

Vertically, serratus anticus major (N. thorac. longus). 
(6) Anteriorly, anterior portion of the deltoid (N. axillaris). 

Coracobrachialis (N. musculocutaneous). 

Biceps (N. musculocutaneous). 
(c) Posterior portion of the deltoid (N. axillaris). 

2. Adduction of the arm. 

Pectoralis major (N. thorac. anticus, 5th and 6th cerv. n. ). 
Latissimus dorsi and teres major (N. subscapulars ). 
Infraspinatus (N. suprascapular, fith and 6th cerv. n.). 
Teres minor (N. axillaris). 

These muscles also depress the arm. 

3. Internal rotation. 

Subscapulars (Nn. subscapulars). 

4. External rotation. 

Infraspinatus (N. suprascapularis). 
Teres minor (N. axillaris). 

C. Movements of the elbow. 

1. Flexion. 

Biceps (N. musculocutan. ). 
Brachialis (N. musculocutan. ). 
Supinator longus (N. radialis). 

2. Extension. 

Triceps (N. radialis). 

3. Supination. 

Supinator brevis | (Kradialis) 
Supinator longus J v ; 

4. Pronation. 

Pronator quadratus 1 (Nmedianus)- 
Pronator teres I v ; 

Supinator longus (N. radialis). 

D. Movements of the wrist-joint. 

1. Flexion. 

Flex, carpi radialis (N. medianis). 
Flex, carpi ulnaris ) ,^ i ■ \ 
Palmaris longus J 

2. Extension. 

Extensor radialis longus and brevis \ ,*r -,- y \ 
Extensor ulnaris J 

3. Abduction. 

EXLTngufand'brevis} < K medianis and K radiaUs )- 

4. Adduction. 

Extensor ulnaris and flexor carpi ulnaris (Nn. radial, and ulnar). 

E. Movements of the fingers. 

1. Flexion. 

Flexor digitor. sublim.; flexion of the 2d phalanx (N. median). 

Flexor digitor. prof.; flexion of the terminal phalanx (Nn. median, ulnar). 

Interossei and lumbrical muscles, flexion of the proximal phalanx (Nn. 

ulnaris, median. 



DISEASES OF THE NERVOUS SYSTEM. 1029 

2. Extension. 

Extensor dig. comm. (N. radialis). 

Interossei and lumbrical muscles (N. ulnar, N. median). 

F. Movements of the thumb. 

1. Flexion. 

Flexor pollicis longus and brevis (N. median). 

2. Extension. 

Extensor pollicis longus and brevis (N. radialis). 

3. Abduction. 

Abductor pollicis long. (N. radialis). 
Abductor pollicis brev. (N. median). 

4. Adduction. 

Adductor pollicis (N. ulnaris). 

5. Opposition. 

Opponens pollicis I (N mediant 

Adductor pollicis brev. / UN ' mecllan )- 

G. Movements of the eittle finger. 

1. Flexion. 

Flexor communis digitorum profundus and sublimis (N. median and N. 
Flexor brevis minimi digiti (N. ulnaris). ulnaris). 

2. Extension. 

Extensor minimi digiti proprius (N. radial. ). 

3. Abduction. 

Abductor minimi digiti (N. ulnaris). 

4. Opposition. 

Opponens minimi digiti (N. ulnaris). 

Lower Extremity. 
A. Movements of the hip- joint. 

1. Elevation of thigh, 

Iliopsoas (N. plexus lumbalis). 
Kectus femoris \ ,„ _ pnrftli -x 
Sartorius P cruralls >- 

2. Depression of thigh. 

Glutseus maximus (Nn. glut. inf. and ischiadicus). 
Flexors of the knee (N. ischiadicus). 

3. Internal flexion. 

Glutseus med. and minim. (N. glut, super.). 

4. External rotation. 

Quadratus femoris ) , XT . , • ■.. N 

Obturator int. and Gemelli } ^' is ^iadicus). 
Obturator ext. CN. obturat. ). 
Pyriformis (Plex. ischiad. ). 
Iliopsoas (Plex. lumbal.). 
Glutaeus max. (N. glutaeus inf. ). 

5. Adduction. 

Adductores (N. obturator). 
Pectineus (N. crural and obturat. ). 
Gracilis (N. obturator). 

6. Abduction. 

Glutseus med. and min. (N. glut. sup. ). 



1030 SPECIAL DIAGNOSIS. 

B. Movements of the knee-joint. 

1. Flexion. 

Sartorius (N. cruralis). 
Gracilis (N. obturat.). 
Semitendinosus \ 
Semimembranosus mN. ischiad. ). 
Biceps. J 

Popliteus (N. tibial, N. ischiad.). 

2. Extension. 

Quadriceps (N. cruralis). 

C. Movements of the ankle-joint. 

1. Dorsal flexion. 

Tibial antic. 1 / v ^ \ 

Extensor commun. dig. long. } ( N " P eron " P rof )' 

2. Plantar flexion. 

Gastrocnemius! / AT ,. u . , x 
Soleus [(N. tibial). 

Perineus long. (N. peron. superficial). 

3. Adduction. 

Tibial postic (N. tibial). 
Tibial ant. (N. peron. prof. ). 

4. Abduction. 

Peroneus long. ^ 

Peroneus brevis V (N. peron. prof.). 

Comm. dig. long J 

5. Elevation of the inner side of the foot. 

Tibial ant. (N peron prof. ). 
Tibial post. (N. tibial). 

6. Elevation of the outer side of foot. 

D. Movements of the toes. 

1. Flexion. 

Flexor comm. digit, long, and brev. "1,-m- +;K: a i\ 
Interrossei and lumbricales J 

2. Extension. 

Extensor comm. digit, long, and brev. (N. "peron. prof.). 

3. Adduction. 

Interossei plantares (N. tibial). 

4. Abduction. 

Interossei dorsales (N. tibial). 

E. Movements of the great toe. 

1. Flexion. 

Flexor hallucis long, and brev. (N. tibial). 

2. Extension. 

Extensor hallucis long, and brev. (N. peron. prof.). 

3. Adduction. 

Adductor hallucis (N. tibial). 

4. Abduction. 

Abductor hallucis (N. tibial). 



DISEASES OF THE NERVOUS SYSTEM. 



1031 



F. Movements of the smaee toe. 

1. Flexion. 

Flexor minimi digit. (N. tibial). 

2. Abduction. 

Abductor minimi digit. (N. tibial). 

3. Opposition. 

Opponens minimi digit. (N. tibial). 

Each movement should be tested by requesting the patient to per- 
form it first unimpeded, and then against resistance. (For functions 
of motor cranial nerves, see page 1025.) 3. Sensory disturbances. As 
in testing the motor disturbances, there is first obtained a rapid orien- 
tation of the sensory condition of the patient. For this purpose it is 
customary to touch with the finger or a blunt object both sides of the 



Fig. 246. 




Cutaneous nerves of the head and face. 
Vi, V»> V s , first, second, and third branches of the trigeminus; S 0, supra-orbital : I, lachrymal 
st, supratrochlear ; it, infratrochlear ; e, ethmoidal ; sm, malar ; at, auriculo-temporal ; b, buc 
cinator : to, mental ; am, auricularis magnus ; oma and omi, occipitalis major and minor. 

face, the arms, the legs, and both sides of the body. If the patient 
declares that there is no difference in the sensory perceptions, tactile 
anaesthesia may be temporarily excluded. The same regions are tested 
for pain and temperature-sense, and it is often desirable to test the 
muscle-sense at the same time, although this properly belongs to dis- 
turbances of motility. It is often possible, in testing sensation, to decide 
whether the lesion is peripheral or central by its distribution. If it 
affects the spinal cord it will be segmental in type. (See Fig. 244 and 
Fig. 245.) If it affects the peripheral nerves, the area or areas will 
correspond to the cutaneous distribution of the nerve or nerves involved. 
(See Fig. 246 et seq.) 4. The cutaneous trophic changes occur 



1032 



SPECIAL DIAGNOSIS. 



particularly in the form of panaritis of glossy skin or of bed-sores. 
Trophic changes in the joints occur especially in the knee, shoulder, and 
hip. Trophic changes in the muscles may occur in any part of the body. 
They are, of course, nearly always associated with distinct paralysis. 
Having obtained a rough idea of the condition of the patient, it is then 



Fig. 247. 




Cutaneous nerves of the anterior surface of the trunk. (Sahli.) 



necessary to make a more minute examination. 1. The various func- 
tions should be carefully studied, particularly those of the cerebral 
nerves. These should be taken up in order and all their functions 
tested. 2. It is important to note the reflexes, especially those 
of the eye, and the tendon and cutaneous reflexes of the body and 



DISEASES OF THE NERVOUS SYSTEM. 



1033 



extremities. 3. The position, station, and gait. 4. The disturbances 
of speech. 5. The condition of the individual muscles and nerves of 



Fig. 248. 




1 W ■■■ \Ni(nfeicosto- 

f 
% 

cut: 



N.rculial. 




Cutaneous nerves of the anterior surface of the arm. (Sahli.) 

the body. The diagnosis must then be made by the study of the symp- 
toms elicited. It should be, if possible, both topical and pathological, 
although it is not always possible to make the latter. 



SPECIAL DIAGNOSIS OF DISEASES OF THE NERVOUS 

SYSTEM. 

The semeiological classification of nervous diseases presents many 
difficulties. Many of the diseases that are closely analogous in their 



1034 



SPECIAL DIAGNOSIS. 



symptoms are widely different in their pathology or etiology, and 
many diseases present such variations in their symptom-complex that 
at one period they could properly be placed in one group and at 
another period elsewhere. In general, it may be said, however, that 
the diseases of the peripheral motor neurons differ so widely from 
those of the central motor neurons that they can be classified as two 
separate groups, and in a third group would come the diseases of the 
sensory neurons. Combinations of these three groups, producing on 
their part rather clearly marked complexes of symptoms, may then be 
described, and finally the general and local diseases of the brain and 

Fig. 249. 





'Medianus 



Distribution of the cutaneous nerves in the hand. 



cord. An entirely separate group, characterized by peculiar symptoms, 
are the so-called functional nervous diseases, or the neuroses. It must 
be admitted, however, that this group, as a result of more accurate 
methods of investigation, is growing rapidly smaller. 



Diseases of the Peripheral Motor Neurons and the Muscles. 

Diseases Characterized by Pure Motor Disturbance. 

Progressive Muscular Atrophy. Two forms are recognized — the 
scapulo-humoral type of Erb and the facio-scapulo-humoral type 
of Dejerine-Landouzy. In the former the disease commences in the 
muscles of the shoulder, especially the pectorals and the latissimus 
dorsi. Next the adjacent muscles are involved, followed by the 
muscles of the arms, thighs, and finally the muscles of the calf. 
There is gradual loss of power corresponding to the atrophy of the 
muscles, but reactions of degeneration do not occur. As a result of the 



DISEASES OF THE NERVOUS SYSTEM. 



1035 



wasting, peculiar alterations occur in the configuration of the body — 
that is, the shoulder-blades become prominent, lordosis occurs, and, as 
a result of the weakness of the glutei, it may be necessary for the 



Fig. 250. 




N. cut. brach. ext. (From 
the N. musculocuta- 
neus). 



N median. 
Cutaneous nerves of the posterior surface of the arm. (Sahli.) 



patient to arise, as in the following form, by climbing up his legs. 
The gait, as a result of the atrophy of the cpadriceps, is waddling in 
character. The disease usually presents itself about puberty. 

In the latter type the symptoms are essentially the same, excepting 
that the first muscles to undergo atrophy are those of the eyelids and 



1036 



SPECIAL DIAGNOSIS. 



mouth. This form usually commences about the third or fourth year 
of life. 

Pseudo-hypertropliic Muscular Paralysis. The disease usually com- 
mences in the muscles of the calves. These become greatly enlarged, 
hard, and there is great loss of power. Other muscles of the legs are 



N. peroneus 



N. peroneus superf. 



Fig. 251. 



' W'.J*' 







N. pud. coram, (pi. sacr.) 
N. cut. fern. post. (pi. (sacr.) 

N. obturator, (pi. lumb.) 



^* N. peroneus prof. 



N. plant, int. 



N. cut. dorsi pedis ext. 
N. plant, ext. 
Cutaneous nerves of the anterior surface of the leg. (Sahli. 



next involved ; then those of the back, and perhaps the arms. Not all 
the muscles that undergo atrophy show a preliminary hypertrophy. 
The electrical reactions remain normal, and the loss of power is due 
merely to the atrophy of the true muscle substance. The gait is 
waddling, and the patient is unable to arise from the ground, except 
by getting upon the hands and knees and then gradually climbing up 



DISEASES OF THE NERVOUS SYSTEM. 



1037 



his legs. There is usually lordosis or scoliosis, and occasionally con- 
tractures occur, leading to formation of club-foot. In all these three 
forms of disease the course is slowly progressive. 



Fig. 252. 



\Iumb.e^sacnJ 



N. obturatorius 




N. saphenus rnaj 



N. cut. fern. lat. (pi. lumb.) 



N. communicans tibial et 
peroneus. 



^-' N. peroneus supernV. 

, - N. cut. dorsi pedis ext. 
--■ N. plant, ext. 



Cutaneous nerves of the posterior surface of the leg. (Sahli. 



Diseases Characterized by Motor Disturbance, with Degen- 
erative Changes in the Muscles. 

Progressive Muscular Atrophy Consecutive to Disease of the Nerves. 
(The Charcot-Marie-Hoffmann type ; the peroneal type of Gowers.) 
The first muscles affected are those of the feet and hands, usually in 
the former, the peronei, the extensors of the toes, and the small muscles 



1038 SPECIAL DIAGNOSIS. 

of the foot ; in the latter, the interossei and the muscles of the thenar 
and the hypothenar eminences. The affected muscles show distinct 
fibrillary twitchings and usually the characteristic reactions of degenera- 
tion to the electrical current. These reactions of degeneration are also 
present in the nerves. There is usually a coarse, irregular tremor, and 
the atrophy of some of the muscles with contractures of others give rise 
to various deformities, such as the ape-hand, the main en griffe, or, if 
the foot is first affected, to foot-drop. Later the foot assumes a posi- 
tion of equino valgus or varus. In this disease there is sometimes 
involvement of the sensory fibres, and the patients may complain of 
slight paresthesia or even of pain. Hypsesthesia is also occasionally 
present. In a form of this disease described by Dejerine under the 
title of Infantile Hypertrophic and Progressive Interstitial Neuritis, 
there are, in addition to the above changes, the symptoms of locomotor 
ataxia — that is, Komberg's symptom — lancinating pains, atactic gait, 
and even disturbance of the pupillary reflexes. The nerve-trunks 
become enlarged and can be felt beneath the skin. 

Progressive Spinal Muscular Atrophy. (Type of Duchenne-Aran.) 
The disease commences usually in the muscles of the hand, particularly 
in those of the thenar eminences, giving rise to the formation of the 
ape-hand. The interosseous spaces become deeper, the fingers become 
gradually weakened, and ultimately become fixed in a semi-flexed con- 
dition — incomplete main en griffe. The muscles show fibrillary twitch- 
ing and give the reactions of degeneration to the electrical current. 
Usually the process is bilateral. As the disease progresses it next 
involves the muscles of the shoulder, especially the deltoids, and later 
the muscles of the upper arm, and then of the forearm. Finally, the 
muscles of the back become involved, and even the lower extremities. 
Sensory disturbances are never present. The emaciation is extreme, 
but total paralysis occurs only very late in the disease. 

Acute Anterior Poliomyelitis. This is really an infectious disease, 
commencing with chills and fever and characterized by the rapid ap- 
pearance of flaccid paralysis in one or more limbs. The onset is usually 
sudden, and the paralysis may occur before the development of the 
general symptoms. The legs are more frequently involved than the 
arms ; the muscles are usually affected in functionally similar groups, 
such, for example, as the flexors of the upper arm, and then very rapidly 
begin to undergo contractures. These produce deformities, particularly 
various forms of club-foot, scoliosis or lordosis, and contractures of 
the hand. The disease usually occurs in children, and the affected 
extremity does not grow as rapidly as the other. Occasionally adults 
are attacked. Sensory disturbances are absent, the reflexes are abol- 
ished, and the electrical reactions are those of degeneration. In the 
very early stage pains, usually radiating from some point in the back, 
have been noted in a few instances. Ordinarily, the paralysis is more 
extensive at first than later — that is to say, many of the muscles 
involved recover completely. 

Chronic Anterior Poliomyelitis. This is characterized by the slow 
development of paralysis in one or more groups of muscles or extremi- 
ties of the body. The flexors are more likely to be attacked than the 



DISEASES OF THE NERVOUS SYSTEM. 1039 

extensors. The muscles show fibrillary twitchings and the reactions 
of degeneration, and the paralysis is usually flaccid. The process is 
usually self -limited, but bulbar symptoms may appear and cause death. 
The disease resembles closely progressive spinal muscular atrophy. 

Periodic Paralysis. This is a disease characterized by the occur- 
rence from time to time of paralysis of all four extremities. The 
paralysis is usually flaccid in type, occurs without pain, and is associ- 
ated with extraordinary increase in the electrical resistance of the skin. 
The disease usually occurs in several members of the same family, the 
paroxysms lasting three or four days. 

Diseases Characterized by Disturbance of Motion Occurring 
without Reference to any Definite Portion of the Cere- 
bral Nervous System. 

Chorea (Sydenham's chorea) is characterized by irregular twitching 
movements affecting various groups of muscles in the body that are 
usually functionally associated, so that the movements appear to be the 
result of voluntary innervation. These movements may be generally 
distributed, or more pronounced on one side than the other, or may 
even occur only in one part of the body. They may involve the muscles 
of the face, the arm, the leg, or the muscles of the trunk, particularly 
the diaphragm, giving rise to an irregular, jerking inspiration. They 
may vary in severity from slight, almost imperceptible contractions to 
severe, general convulsive movements in which the violence is so great 
that bruises or even fractures may occur. As a rule, the affected limbs 
are slightly weaker, and in some cases this paralysis is very pronounced 
(paralytic chorea). The mind is usually clear, but there may be some 
irritability of temper. In a few cases with violent movements there is 
pronounced insomnia and violent delirium (chorea insaniens). Speech 
may be affected either as a result of choreic movements of the lips or on 
account of psychic disturbance. Associated symptoms are the presence 
of a heart murmur, irregularity of cardiac action, rheumatic pains in 
the limbs, which usually disappear as the movements become more 
pronounced ; and, occasionally in the violent form, fever. 

Huntington's chorea is characterized by the development, between the 
ages of twenty and forty, of choreiform movements of moderate degree, 
associated with gradually progressive dementia. The disease is strictly 
hereditary, occurring only in the offspring of those who have suffered 
from it. The twitchings resemble those of chorea, but are rarely vio- 
lent, and often associated with a slight rigidity. The first mental 
symptom is usually loss of memory. Later, the patient may have 
delusions of grandeur or severe melancholia. Usually life is prolonged 
to an advanced age, the mental symptoms gradually passing into the 
type of severe senile dementia. A curious condition is the tendency 
of the patient to avoid society. 

Chorea Electrica. There are various varieties of this condition — one 
occurring in children, characterized by lightning-like contractions of 
groups of muscles, sometimes those of the trunk or those of the ex- 
tremities ; another, Dubinins disease, which appears to be an infectious 



1040 SPECIAL DIAGNOSIS. 

process, commences with violent pains in the head, neck, and back, slight 
fever, and general convulsions. Muscular contractions occur, usually 
involving all the muscles of the body that are characterized by their fre- 
quent recurrence and brief duration. Death is the usual termination. 

Paramyoclonus Multiplex. This is a disease, probably hysterical in 
nature, characterized by lightning-like contractions in groups of muscles, 
which do not, however, produce movement that would in any way 
resemble co-ordinated action. Often the patient from time to time 
emits a peculiar sound resembling a grunt, probably the result of 
diaphragmatic involvement. The electrical reactions are normal, and 
the reflexes are sometimes slightly increased. 

Habit spasm is characterized by the repetition of some peculiar, 
unnecessary movement, such as shrugging the shoulders, winking the 
eye, rubbing the elbow against the side, etc. Emotional disturbances 
or the presence of bystanders always increase the symptoms. 

Saltatoric spasm (jumper's disease, latah) is a hysterical manifesta- 
tion in which the patient, whenever he or she attempts to stand, is 
compelled to rise on the toes or even to spring from the ground. 
Often after such movements the patient falls. The spasm disappears 
if the patient lies down, but may be produced by pressure upon the 
soles of the feet. 

General Tic (Ifaladie de Gilles de la Tourette ; maladie der tics con- 
vulsifs). This is a psychical condition characterized by curious move- 
ments of the limbs and grimaces and the utterance of words, that have 
no relation to the evironment, that may be profane or obscene (copro- 
lalia), or the imitations of sounds heard (echolalia). The patient becomes 
more or less melancholy, and may even be violently insane. 

Paralysis Agitans. This is characterized by a peculiar, fine tremor 
of the extremities, rigidity of the muscles, disturbance of gait, and 
gradually progressive paresis. The first symptom noted is usually a 
slight impairment of agility. As the disease commences in advanced 
life, this is not regarded with suspicion ; but later the immobility of 
the muscles of the face and the complete loss of facial expression sug- 
gests the nature of the case. It will now be found that the patient 
will have difficulty in rolling over, if lying down, and that there is dif- 
ficulty in commencing to walk and afterward a tendency to take quick 
steps (festination). The patient, if studied, will be seen to have from 
time to time a slight movement forward or backward, which, if stand- 
ing or walking, may cause him to fall in one direction or the other 
(propulsion, retropulsion). Speech is also involved, difficulty in articu- 
lation being characterized at first by slight halting and then the rapid 
utterance of the words. The tremor of the hands is spoken of as pill- 
roller's tremor (q. v.). Tremor of the head is a nodding movement to 
and fro. There may also be irregular movements of the toes or legs. 
The tremor is diminished or abolished temporarily by voluntary move- 
ment and disappears during sleep. 

Tetany is probably an infectious disease characterized by cramp of 
the muscles of the arms and the persistence of peculiar nervous and 
mental alterations. The attack usually commences with paresthesia or 
pain in the limbs ; then the muscles controlling the fingers become stiff. 






DISEASES OF THE NERVOUS SYSTEM. 1041 

The flexors gradually contract and draw the fingers and thumb together, 
the so-called obstetrical hand. This cramp is tonic in character, and 
may last for several minutes or ev T en for many hours. It is often asso- 
ciated with intense pain During the interval it may be reproduced 
by prolonged, severe pressure upon the nerve-trunks, particularly the 
median nerve (Trousseau's sign). The muscles show marked irrita- 
bility to mechanical stimuli, particularly those of the face, and twitch- 
ing may be caused by tapping upon the trunk of the facial nerve, upon 
the malar bone, or over the infraorbital foramen (Chvostek's sign). 
The muscles show extreme electrical irritability, contract to very weak 
currents, and in some cases AOTe and COTe have been obtained 
(Erb's sign). Finally, the patient is extremely sensitive to the induced 
current (Hoffmann's sign). During the attack, and even during the 
interval, there is sometimes slight oedema of the face, hands, and feet, 
and the latter have a tendency to assume a partial equino-varus posi- 
tion. Often there is slight fever. 

Occupation Neuroses. These are characterized by the development 
of pain in the limb employed when the attempt is made to perform 
some habitual movement. It is most common as a result of writing. 
The patient notices at first that he becomes more readily fatigued than 
usual, and there may be dull pains in the joints or in the palm of the 
hand. The painful sensations may then extend up the arm, often as 
far as the shoulder. They are rarely severe, but by their persistent, 
dull character are extremely annoying. The motor symptoms are 
characterized by a tonic spasm of the muscles employed in grasping 
the pen, so that it is held too tightly, and often there is difficulty in 
holding it properly. From time to time the spasmodic condition may 
increase and cause inaccurate strokes. The writing is usually heavy and 
often quite illegible. The muscles apparently never degenerate. The 
electrical reactions are normal or only slightly altered. If the patient 
learns to write with the left hand, the symptoms of the disease usually 
develop in it after a short time. Similar symptoms occur in piano- 
players, violin-players, dairy-maids, telegraphists, and various other 
persons who are obliged to perform the same movement for long periods. 

Thomsen's Disease. This is characterized by the occurrence of tonic 
spasm as the result of voluntary innervation of the muscles. The 
patient, upon attempting to make a movement, finds the part rigidly 
fixed for a longer or shorter interval of time. The spasm then relaxes, 
the movement can be performed, and does not recur while the muscles 
are kept active. There are occasionally cramp-like pains in the mus- 
cles and a peculiar alteration in the electrical reactions. (See Myotonic 
Reaction.) The disease is chronic, but subject to exacerbations, partic- 
ularly as a result of exposure to cold, previous excessive exercise, or 
emotional disturbance. 

Diseases of the Sensory Neuron, with Disturbances of 

Sensation. 

These are generally included under the term neuralgia. Neuralgia 
is a condition characterized by pain of a dull, burning, or shooting 

66 



1042 SPECIAL DIAGNOSIS. 

character that occurs in the distribution of some particular sensory 
nerve or nerves. The pain may be remittent or intermittent. It is 
exaggerated, as a rule, by external irritation or emotional disturbance. 
The nerve-trunk is often tender, not only during the attack, but also 
during the interval. Associated symptoms are often present. The 
most common are the vasomotor disturbances, the area of distribution 
of the affected side showing persistent or paroxysmal flushing or occa- 
sionally pallor. Secretion of sweat is sometimes increased, and there 
may be exaggeration of the activity of glands supplied by the nerve. 
Occasionally there is marked oedema of the skin, and sometimes a 
herpetic eruption. Very rarely in neuralgia there is local graying of 
the hair. Motor symptoms may also occur. These consist of spas- 
modic twitching that may be associated with exacerbations of the pain. 
Neuralgias due to various general conditions sometimes have a charac- 
teristic localization. Thus in diabetes, sciatica occurs ; in malaria, 
supra-orbital neuralgia ; in neurasthenia, occipital neuralgia. 

Special Forms. Neuralgia of the Trigeminal Nerve (tic douloureux). 
This usually occurs in only one branch of the nerve, and is commonly 
unilateral. The pain is paroxysmal and very severe, and is often 
referred by the patient to some supposed source of peripheral irritation, 
as disease of the nose, carious teeth, etc. It is usually associated with 
increase in the secretion of various glands, such as the tear glands, the 
salivary glands, the nasal mucous membrane, etc. Trophic changes 
are not uncommon. These may vary from herpetic eruptions and 
graying of the hair to atrophy of the soft parts and even of the bones 
of the face. Occasionally trophic alterations of the cornea also appear. 

Occipital Neuralgia. This involves the occipitalis major nerve, but 
occasionally the auricularis magnus and the nerves of the neck are also 
affected. The pain is distributed over the occipital region of the head, 
and is usually bilateral. The point of greatest tenderness is over the 
cervical vertebrae, usually slightly to one side of the spinous processes. 

Brachial neuralgia is characterized by pain distributed in the arm of 
the affected side. This may be either persistent or paroxysmal. If 
the latter, parsesthesise in the hand or arm are frequent during the 
intervals. The points of tenderness are found where the nerves pass 
over the bones or just behind the clavicle. Occasionally trophic changes 
are observed. 

Intercostal neuralgia is characterized by pain distributed along the 
course of the intercostal nerves. There are three characteristic tender 
points — one next to the spinal column, one in the axillary line, and 
one over the sternum or rectus abdominus. There are usually trophic 
disturbances in the skin over the affected nerve, characterized by red- 
dening or especially by a herpetic eruption (herpes zoster). 

Lumbar neuralgia is characterized by pain radiating from the lumbar 
to the gluteal region. Occasionally the anterior surfaces of the thighs 
are also involved. The sensitive points are found over the lumbar 
vertebrae along the edge of the crest of the ilium and over the linea alba. 

Crural neuralgia is characterized by pains radiating from the front 
of the thigh into the feet. Paresthesia? are frequently present during 
the intervals of the attacks. 



DISEASES OF THE NERVOUS SYSTEM. 1043 

Sciatica is characterized by pain in the posterior surface of the thigh, 
often radiating to the feet. It is an exceedingly common form, usually 
paroxysmal in character, the attacks being preceded by paresthesias. 
The pain is increased by any movement tending to stretch the nerve, 
and as a result the patient walks with a peculiar gait, the thigh of the 
affected side being held fixed and parallel to the body. This some- 
times results in a slight curvature of the spine. The nerve is often 
sensitive through its entire length. The special points of tenderness 
are found near the posterior superior spine of the ilium, at the lower 
edge of the gluteus maximus, just outside the tuber ischii, and in the 
cavity of the knee-joint. The reflexes are usually slightly exaggerated. 
There is sometimes slight weakness of the muscles and occasionally 
fibrillary twitchings. 

Other forms of neuralgia are mastodynia, or irritable breast ; neuralgia 
of the phrenic nerve, characterized by deep pain in the thorax and slight 
dyspnoea ; coccygodynia ; and various neuralgia-like pains in the viscera. 

Diseases somewhat similar to neuralgia are meralgia paresthetica, 
characterized by tingling, burning, or tearing in the area of the distri- 
bution of the external cutaneous nerve of the thigh, usually unequally 
bilateral, and made worse by prolonged exercise, either walking or 
standing. Frequently there is a tender point just below the anterior 
superior spine of the ilium. Sensory disturbances in the form of 
hypsesthesia, hypalgesia, and diminished electro-cutaneous sensibility 
are very common. 

Achroparcesthesice are characterized by tingling or pain in the extremi- 
ties. The affected members are usually tender, and there is hyperes- 
thesia. Occasionally vasomotor disturbances are present. An allied 
condition is the symptom known as tender toes that occurs in the course 
of typhoid fever. 

Diseases of the Sensory Neuron Characterized by Disturb- 
ance of Motion, Sensation, and Trophic Disorders. 

Tabes Dorsalis. This is characterized by ataxia, particularly of the 
lower extremities, lancinating pains in the legs, loss of the knee-jerk, 
and the Argyll-Robertson pupil. It is divided into three stages : the 
preatactic, the atactic, and paralytic. The symptoms of the preatactic 
stage frequently commence with disturbance in the nerves affecting 
the eyeball. There may be paresis of the abducens, giving rise to 
diplopia ; of the levator palpebral, giving rise to ptosis ; or sluggish or 
absent reaction to light on the part of the pupil, while the reaction of 
accommodation still persists (Argyll-Robertson pupil). The symptoms in 
the nerves of the lower extremities are particularly the lancinating pains 
that are felt in the posterior portion of the thigh. These come on from 
time to time, and the patient feels as if he has been stabbed. They are 
more frequent in damp weather, and are frequently confused with rheu- 
matism. The knee-jerk is absent, and the patient may note that it is a 
little bit more difficult to walk in the dark. The station in the early stage 
is usually only slightly affected. There is a sense of constriction about 
the body (girdle pain), and sometimes hypsesthesia of the lower extremi- 



1044 SPECIAL DIAGNOSIS. 

ties that may be associated with a slight hyperalgesia in the zone just 
above it. The patients may also remark that they have slight difficulty 
in urination and some diminution of sexual potency. The second 
stage, or the stage of ataxia, is characterized by the symptoms of the 
preceding stage, all of which are now pronounced. In addition the 
patient exhibits inco-ordination of movement, especially in the lower 
limbs. Station is so impaired that it is usually impossible for him 
to stand alone with the eyes closed and the feet together. Walk- 
ing in the dark is difficult and usually associated with frequent falls. 
In the daylight, with the aid of the eyes, the patient can usually 
walk quite well, but lifts the feet higher than usual from the ground, 
and separates them widely. (See Ataxic Gait.) The inco-ordination is 
manifested by the difficulty with which the patients perform certain 
movements, such as touching some object with the tip of the linger — as, 
for example, the nose, ear— or in bringing the heel of one foot against 
the knee of the other. There is diminished muscle-tone, and, of course, 
absolute loss of tendon reflexes, even when reinforced. There are 
paresthesia?, especially in the lower extremities ; analgesia in the same 
situation, or sometimes delay in the conduction of pain. Micturition is 
sometimes difficult ; at others there is incontinence, but insufficiency 
of the sphincter ani rarely occurs. Impotence is complete. The 
Argyll-Robertson pupil is present ; there is usually myosis, nyctalopia, 
and occasionally atrophy of the optic nerve. In the latter condition 
it has been noted that when blindness has fully developed the ataxia 
becomes less pronounced or may disappear completely. The visceral 
crises are characterized by attacks of intense pain involving usually 
the stomach or sometimes affecting the larynx or heart or other viscera. 
The laryngeal crises are often accompanied by distressing cough and 
dyspnoea. Trophic changes occur, of which the most common are the 
arthropathies. These involve particularly the knee, hip, and shoulder- 
joints. In addition, the patient may have painless falling out of the 
teeth or rapid softening of them. In certain cases a chronic ulcer 
develops on the sole of the foot, which usually progresses until it has 
produced perforation (mat perforante). In the paralytic stage of ataxia 
the loss of muscle-tone has reached such an exreme degree that loco- 
motion is impossible. The patients by this time have usually developed 
cystitis, and death occurs either as a result of exhaustion or of general 
septicaemia. 

The Cervical Type of Tabes Dorsalis. This is characterized by 
the development of the symptoms chiefly in the arms. The lightning 
pains are found in the upper extremities, there is loss of the bicipital 
and tricipital reflexes, and the girdle sensation is usually felt in the 
upper part of the thorax. The ocular symptoms are the same. The 
visceral crises are likely to affect the larynx. In this form ataxia in 
the legs, Romberg's symptom, and the absence of the knee-jerk may 
not be present until late in the disease. 

Friedreich's Ataxia. This is characterized by inco-ordination, loss 
of knee-jerk, weakness, irregular speech, and slight deformities. The 
disease commences in youth, and is usually hereditary in character. 
The first symptom is inco-ordination of the lower limbs. This gradu- 



DISEASES OF THE NERVOUS SYSTEM. 1045 

ally becomes more severe, the muscles grow weaker, the flexors more 
so than the extensors, often giving rise in time to pes equino-varus. 
The muscles of the back also grow weaker, giving rise to scoliosis ; the 
knee-jerks are absent, the pupillary reflexes remain normal, and intelli- 
gence is unaffected. The speech is peculiar, some of the syllables being 
pronounced readily and others slowly, with a drawl. The gait becomes 
markedly ataxic, the patients keeping the legs widely separated. In 
time the paresis and inco-ordination become so severe that walking 
is impossible. The disease is progressive and usually affects several 
members of the same family. 

The cerebellar type of hereditary ataxia differs from the foregoing by 
the fact that the knee-jerks are exaggerated, and there is occasionally 
absence of the pupillary reflex to light. 

Diseases of the Peripheral Motor and the Sensory Neuron. 

These are all characterized by disturbances of motion and sensation, 
usually associated with more or less severe trophic changes. 

Neuritis. Inflammation of the nerves is characterized by pain local- 
ized in the nerve affected, tenderness, and perhaps paresis or paralysis 
of certain groups of muscles. The pain is made more severe if the 
limb is held in such a position that the nerve is stretched. As it is a 
true inflammatory condition, there are usually constitutional disturb- 
ances, such as fever, malaise, etc. Often the disease is progressive, 
extending from the peripheral to the more central nerve-trunks. This 
is spoken of as ascending neuritis. Along the course of the nerve there 
are often vasomotor and secretory disturbances, or the lesions may be 
more severe, such as atrophy of the skin, with glossiness, or trophic 



Fig. 253-. 



V 

-4T 



Is d&- 



Alcoholic neuritis. Foot-drop and wrist-drop. 



changes in the nails. Multiple neuritis is characterized by the appear- 
ance of the symptoms of the disease in a number of nerves at the same 
time. The nerves of the limbs are far more frequently affected than 
those of the trunk. The symptoms are modified by the cause. In 
alcoholic polyneuritis there are usually slight paresthesias of the limbs, 
with marked paresis of the muscles, particularly the extensors, giving 
rise to foot-drop and wrist-drop. (See Fig. 253.) The disease usually 
affects all four extremities. In lead-poisoning the disease is sometimes 
unilateral, is usually restricted to the arms, and the sensory disturb- 



1046 SPECIAL DIAGNOSIS. 

ances are very slight or absent. There is paralysis of the extensor 
muscles of the arm, which in severe cases goes on to muscular degen- 
eration. Neuritis may also be produced by arsenic. Diphtheritic poly- 
neuritis is usually characterized by paralysis of the muscles of the 
palate, but occasionally the muscles of the limbs are also involved. 
In certain of the chronic forms of polyneuritis, instead of loss of power, 
there is marked loss of co-ordination. This is spoken of as the ataxic 
variety. 

Beri-beri, or kakke, is an infectious disease characterized by the symp- 
toms of a peripheral multiple and symmetrical neuritis. The patients 
usually present general symptoms, as fever and chills, and then com- 
plain of a sense of weakness or heaviness in the legs, paresthesia?, and 
diminution of tactile sensation. The electrical examination of the 
muscles of the legs usually shows the reactions of degeneration. Later, 
the muscles undergo further degeneration and become paralyzed. There 
is oedema of the skin, and the anaesthesia becomes more pronounced. 
Occasionally pain-sense is preserved, giving rise to anaesthesia dolorosa. 
The paralysis becomes more extensive, and the patient may die as a 
result of the involvement of the respiratory muscles. 

Multiple neuromata sometimes occur very extensively upon the nerves 
of the skin, at times producing symptoms of multiple pressure upon the 
nerves — that is, paresthesia?, paralyses, or loss of sensation. At other 
times they produce no symptoms whatever, and can only be recognized 
by inspection. 

Diseases of the Spinal Cord Involving the Central Motor 

Neurons. 

Primary spastic paraplegia is characterized by weakness of the legs 
without muscular degeneration and with increased reflexes. The dis- 
ease was formerly supposed to be the result of the involvement of the 
lateral columns of the cord. The first symptoms are weakness or a 
feeling of heaviness in the legs ; then spontaneous cramps appi ar. 
The reflexes are greatly exaggerated, and the muscle tone is so in- 
creased, particularly in the extensors of the thigh or knee and foot, that 
the patient walks with the leg partially extended, dragging the toe 
along the ground ; the arms are rarely involved. The electrical reac- 
tions of the muscles are normal. The sphincters are very rarely in- 
volved, and sensation is usually unimpaired. If cramps are frequent, 
however, the muscles may be sore. In children the adductors become 
stronger than the abductors, and a peculiar, crossed-legged gait is there- 
by produced. 

Amyotrophic Lateral Sclerosis. This is characterized by a spastic 
paraplegia, with exaggeration of the reflexes and degeneration of the 
muscles. The symptoms consist of weakness in the legs, which at the 
same time become stiff. The muscles rapidly atrophy ; there are fibril- 
lary twitchings and reactions of degeneration. The arms are usually 
involved first, the degeneration commencing in the muscles of the hands 
and giving rise ultimately to the production of various deformities, such 



DISEASES OF THE NERVOUS SYSTEM. 1047 

as the claw-hand. The tendon reflexes are greatly exaggerated ; there 
are patellar clonus and ankle clonus. The muscles are greatly weakened, 
but remain rigid until late in the course of the disease. The sphincters 
are rarely involved, the pupillary reflexes are normal, and there are 
no sensory disturbances. Bulbar symptoms — that is, paralysis of the 
larynx, pharynx, and palate — occur, giving rise to dysphagia, alteration 
in speech, and frequently causing an inspiration pneumonia. 

Multiple Sclerosis. This is a condition that involves the sensory and 
motor tracts in the spinal cord and occasionally in the brain. The 
characteristic symptoms are intention tremor, nystagmus, and scan- 
ning speech. The patient usually has weakness of the legs, with some 
tremor and exaggeration of the reflexes. In the arms the same con- 
ditions are present, and in the attempt to grasp any object a violent 
tremor is developed, which continues until the movement has been 
accomplished. Various areas of anaesthesia are also present, depending 
largely upon the localization of the lesions. There is usually persistent 
nystagmus, lateral in character ; the speech is slow and drawling, and 
the patient has a tendency to laugh or weep without provocation. In 
a large proportion of the cases there is more or less complete atrophy 
of the optic nerve. Less frequent symptoms are vertigo, occurring in 
paroxysmal attacks, diminution of intelligence, and occasionally dis- 
turbances of the function of the bladder, and in a few cases atrophy 
and degeneration of the muscles. The disease is usually chronic, but 
from time to time there are exacerbations. It appears to be frequently 
associated with hysterical manifestations. In some cases bulbar symp- 
toms appear early and rapidly lead to death. 

Hypertrophic Cervical Pachymeningitis. This is characterized by pain 
in both arms, followed by muscular degeneration commencing in the 
hands. Later, there may be spastic paraplegia of the legs, with anaes- 
thesia of the body below the affected segment. Occasionally this 
disease, which is usually due to tuberculous meningitis, may occur in 
other portions of the spinal cord, giving rise, therefore, to various 
symptoms. 

Acute spinal meningitis is characterized by intense pain in the back, 
radiating into the legs ; rigidity of the spinal column, with opisthot- 
onos ; intense hyperesthesia of the skin of the body, and, if the dis- 
ease lasts long enough, paralyses. Kernig's symptom — that is, the 
inability to extend the flexed leg as a result of flexor cramp — is said 
to occur only in this condition and in cerebral spinal meningitis. The 
tdche spinale occurs also in other conditions. 

Syphilitic spinal meningitis produces a great variety of symptoms. 
There are, however, pains due to pressure upon the posterior roots, 
girdle pains of the body, and occasionally paralysis of the muscles of 
the extremities, with atrophy and degeneration. Often, also, the spinal 
cord is involved, giving rise to the symptoms of pressure or transverse 
myelitis (q. v.) or Brown-Sequard's syndrome (q. v.). The sensory symp- 
toms, aside from the pains, consist of hyperesthesia, hypaesthesia, or 
anaesthesia. The tendon reflexes of the lower extremities may be lost 
and reappear, and this by some is supposed to be pathognomonic of the 
disease. 



1048 SPECIAL DIAGNOSIS. 

Diseases Characterized by the Syndrome of Transverse 
Interruption of the Spinal Cord. 

Potfs Disease (caries of the vertebrae). This is characterized by an 
angular deformity of the spine, spastic paraplegia, and various disturb- 
ances of sensation in the body below the level of the lesion. In the 
earlier stage the only symptoms may be pain in the back, usually radi- 
ating around toward the ventral surface. There may be no deformity, 
but sudden pressure upon the head, jarring of the spine by coming 
down heavily upon the heels, and pressure over the tender point in the 
back may elicit sharp pains. In this stage there are usually slight 
exaggeration of the reflexes and perhaps a slight Aveakness of the legs. 
Later, the angular deformity becomes apparent, usually in the form of 
a sharp projection in the dorsal portion of the spinal column, but it 
may appear also in the cervical and lumbar region. The weakness of 
the lower extremities becomes more pronounced, and may give rise to an 
actual paraplegia. The pains are usually severe, radiate around the 
trunk, and sometimes affect other portions of the body. Sensation 
may be slightly impaired. There may be distinct dissociation below 
the lesion — that is, loss of temperature and pain senses, with preserva- 
tion of tactile sense — or there may be total anaesthesia. As in myelitis, 
bed-sores or other trophic changes of the skin are very likely to develop, 
and the patients suffer severely in general nutrition. In the earlier 
stages, and more particularly in the stage of recovery, after the de- 
formity has become stationary, ataxia may exist. The reflexes are 
sometimes greatly exaggerated, and there is often ankle clonus. When 
the paraplegia has become complete all the reflexes are usually abolished. 
Girdle sensation is also very common. The course is very variable. At 
times the destruction of the body of the vertebra is rapid, and the symp- 
toms develop acutely. At others it occurs very slowly, and the symp- 
toms, even after years' duration, may be exceedingly slight. Caries of 
the upper cervical vertebrae produce pains that involve the neck and 
the occipital region of the head. The position of the head is peculiar ; 
it is drawn slightly forward and carried very rigidly, and the chin is 
elevated. These patients may sometimes die suddenly as a result of 
pressure by the odontoid process on the medulla. 

Tumors of the Membranes. The symptoms of this condition are ex- 
tremely variable, according to the location, nature, and extent of the 
growth. Occasionally deformities occur as a result of pressure upon 
the arches of the vertebrae. Paraplegia usually develops, sometimes 
very suddenly, sometimes gradually. There is usually exaggeration of 
the reflexes and ankle clonus ; but this in time may disappear, or may 
never occur if the tumor is situated in the lumbar region. When the 
posterior roots are pressed upon there are root pains and the girdle sen- 
sation. Sensory disturbances are more or less complete according to the 
degree of destruction that has occurred in the spinal cord. Dissociation 
of sensation rarely occurs, but anaesthesia is very common. After com- 
plete destruction of the spinal cord at any point trophic changes occur. 

Chronic Internal Meningitis. This is usually characterized by pain 
that radiates into various portions of the body, particularly the limbs, 



DISEASES OF THE NEB VOUS SYSTEM. 1049 

and by more or less hyperesthesia. The motor symptoms con- 
sist of tremors, spasms, and occasionally, when the anterior roots are 
involved, paralyses, with muscular degeneration. In the milder forms 
the only motor symptoms may be inco-ordination of movement. Her- 
petic eruptions along the course of the nerves arising from the 
involved posterior roots are quite common. 

Acute Myelitis. There are a number of varieties of this condition, 
the most common and typical being transverse myelitis. It is an 
acute inflammatory disease associated with constitutional disturbance — 
that is, chills, fever, and malaise, and is occasionally ushered in with a 
convulsion. The symptoms are those of transverse lesion of the spinal 
cord. Ordinarily the dorsal part is affected ; and there are, therefore, 
in the earlier stages weakness and paresthesias of the legs, and perhaps 
a girdle sensation and hyperesthesia over the spine, the zone sup- 
plied by the involved segment. In the course of a few days or hours the 
weakness of the legs increases until there is complete paraplegia. The 
tone of the muscles is enormously exaggerated, the knee-jerks are in- 
creased, and there is both patellar and ankle clonus and often Sinkler's 
toe-jerk. The limbs are usually spastic and kept in a position of ex- 
tension. From time to time the muscles give violent twitches. There 
is complete anesthesia up to the horizontal line surrounding the trunk, 
at Attach point there is girdle sensation, and above it there is a zone of 
hyperesthesia. The muscles supplied by the affected segment atrophy 
and give reactions of degenerations. Those in the region below main- 
tain their nutrition for a considerable time. There is difficulty in 
micturition, usually paralysis of the bladder, and finally overflow from 
retention. The urine becomes alkaline, cystitis develops very rapidly, 
and is often followed by extensive sloughing of the surrounding parts. 
Bed-sores occur early and extend deeply. Trophic lesions also occur 
in the legs, the skin becomes thin and glazed, and the toe-nails are 
brittle. Even arthropathies have occasionally been observed. After 
the acute stage has passed more or less improvement may occur, charac- 
terized by gradual return of power in the legs and partial recovery of 
sensation. 

Acute Focal Myelitis. This gives rise to only part of the symptoms 
described above, depending upon the tracts involved by the process 
and the various nuclei that have been destroyed. There is, therefore, 
usually a monoplegia, associated with exaggeration of the reflexes and 
irregular areas of anesthesia, or, if the focus be in the arm or the leg 
centre, diminution or loss of the reflexes and degeneration of the muscles. 

Disseminated myelitis gives rise to a complicated group of symptoms, 
according to the number, situation, and extent of the lesions. It 
resembles perhaps most closely transverse myelitis (q. v.). 

Chronic myelitis is distinguished from the acute form by the more 
gradual development of the symptoms. The patient first notices weak- 
ness of the legs, perhaps characterized from time to time by complete 
transient loss of power {giving way of the legs). If the reflexes are 
examined at this time, they will be found slightly exaggerated ; later 
they become very markedly increased, and ankle clonus develops. The 
patient also complains, in the early stages, of paresthesie in the limbs 



1050 SPECIAL DIAGNOSIS. 

that may involve the arms as well as the legs, and sometimes the trunk. 
A girdle sensation is also frequently present. Finally, muscular atro- 
phies occur, and even severe trophic disturbances ; the picture ulti- 
mately resembling that of acute myelitis. 

Pressure upon the spinal cord may be produced either by injury to 
the vertebral column or by growths in or hemorrhages into the mem- 
branes. The symptoms are those of transverse lesion. If due to tumor, 
they develop very slowly ; if due to traumatism, as a rule, very rapidly. 
There is weakness or paralysis of the legs, with increase of the muscle- 
tone and exaggeration of the reflexes. Ankle clonus is almost invariably 
present. The pains are usually due to pressure upon the posterior roots, 
and are paroxysmal and lightning-like in character. Girdle sensation 
is also present. The muscles supplied by the segments of the cord 
involved undergo degenerative atrophy. 

Landry's Paralysis. This is characterized by progressive paralysis 
of the legs, arms, and muscles of the throat, leading ultimately to 
death. The first symptoms noted are weakness of the legs, which may 
involve both, or at first only one. This gradually ascends, and at the 
same time the patient notices paresthetic sensations. There are, how- 
ever, few or no objective sensory disturbances excepting occasionally 
a slight hyperesthesia. The reflexes are lost, the muscles are without 
tone, and the paralysis is, therefore, flaccid. Electrical changes do not 
occur, or only in very chronic cases. The paralysis gradually ascends, 
involving the muscles of the abdomen, the thorax, and arms. When 
the thorax is involved the patient usually has rapid respiration, and 
complains of dyspnoea. Later there are symptoms of bulbar involve- 
ment, difficulty in deglutition, and interference with speech. The 
diaphragm becomes paralyzed, and the patients die as a result of 
exhaustion. The intelligence remains normal throughout the disease ; 
there is never loss of consciousness and there is no disturbance of the 
function of the bladder or rectum. Fever does not occur. 

Hemorrhage into the Cord (spinal apoplexy). This is characterized 
by the sudden interruption of the functions of the cord at a certain 
level. There is usually, at the time the hemorrhage occurs, severe 
pain, then rapidly developing paralysis of the legs, which may be 
flaccid if the lumbar region is involved, or spastic if the lesion is 
higher up. Heniatoniyelia into the cervical region may cause paralysis 
of the arms, but death usually occurs suddenly. The sensory dis- 
turbances are irregular in character. At times there is dissociation of 
sensation, more frequently complete anesthesia up to the level of the 
hemorrhage. The patient has no fever, consciousness is not disturbed, 
but there is interference with the functions of the bladder and rectum. 
Occasionally the hemorrhage involves particularly one side of the cord 
or only one-half of the gray matter, producing the syndrome of Brown- 
Sequard (q. v.). The diagnosis can frequently be made from the subse- 
quent course of the case. If death does not occur, rapid improvement 
is usually the rule. The sphincters regain their functions, power 
returns in the limbs, and ultimately the patient may recover com- 
pletely. In some cases, however, the recovery, although pronounced, 
is only partial. 



DISEASES OF THE NERVOUS SYSTEM. 1051 

Syringomyelia (cavity in the spinal cord). This is characterized by a 
group of symptoms whose occurrence together is almost pathognomonic. 
First, dissociation of sensation ; pain and temperature senses are lost ; 
tactile and muscle senses are retained. Second, degenerative atrophy 
of the muscles, associated with fibrillary twitchings and alteration of 
the electrical reactions. Third, trophic lesions which may involve the 
skin, particularly that of the fingers or the joints. The disease appears 
to develop with extreme slowness. The earliest symptoms may be the 
occurrence of painless whitlows — that is, inflammation around the 
finger-nail, with perhaps the ultimate destruction of the nail itself. 
These may recur in one finger after another for several years and 
without the presence of any other symptoms, excepting perhaps a 
slight disturbance of sensation in the fingers. Later, muscular atro- 
phies appear. These involve particularly the muscles of the shoulder 
or the hand. In the latter situation they may give rise to the appear- 
ance that occurs in progressive spinal muscular atrophy. At the same 
time the sensory disturbances become more pronounced, gradually 
ascending the arm and perhaps involving the trunk. The upper 
border forms a horizontal line about the body — that is, the alterations 
are segmental in type. The trophic changes may then assume a more 
severe form, giving rise to deep, painless ulcerations in the fingers, and 
perhaps loss of the terminal phalanges. For a long time the symp- 
toms may remain almost exclusively unilateral, and it is rare for the 
two sides to be equally affected. The motor symptoms, aside from the 
weakness resulting from the muscular atrophy, consist of weakness of 
the legs with exaggeration of the reflexes — that is, spastic paraparesis. 
At times the lower portion of the cord is particularly affected, and then 
the sensory and trophic changes are found in the legs. Station may 
be slightly altered in the latter stages of the disease, but this is by no 
means a characteristic symptom. Ultimately the patient develops scoli- 
osis, trophic changes affect other parts than the hands, giving rise to 
arthropathies, or to a form of dry arthritis with absorption of the bone. 
There may be vasomotor disturbances, and in some cases inequality of 
the pupils. The intellect is undisturbed. The patients ordinarily die 
as a result of exhaustion or pulmonary involvement, but occasionally 
in the latter stages of the disease bulbar symptoms occur. 

Morvan's Disease. This is characterized by the appearance of painless 
whitlows in the fingers, sometimes associated with deep ulcerations of the 
soft parts. There are usually sensory disturbances similar to those 
found in syringomyelia, with the addition of tactile anaesthesia, but 
muscular atrophy rarely exists. The disease is exceedingly chronic. 
It is possibly only a variety of syringomyelia. 

Traumatism of the Spinal Cord. This may either produce destruc- 
tion, partial or complete, of the tissue of the cord itself, giving rise to 
the syndrome of transverse interruption, or else give rise to a group 
of indefinite motor, sensory, and mental disturbances that have been 
grouped under the term traumatic neuroses. (See Hysteria.) The 
symptoms, the result of organic lesion, may come on gradually or 
immediately. They are similar to those produced by pressure upon 
the cord. 



1052 SPECIAL DIAGNOSIS. 



Diseases of the Brain Characterized by General Symptoms and 
Sensory and Motor Disturbances. 

Diseases Characterized by Mental, Motor, Sensory, and 
Sometimes Trophic Disorders. 

External pachymeningitis is a rare condition, usually secondary to 
traumatism or abscess, characterized by fever, headache, often sharply 
localized, and convulsions. Frequently the symptoms are masked. 
If there is much thickening of the membrane, evidence of focal dis- 
ease in the form of paralyses or convulsions may be present. Hcema- 
toma of the dura mater is a condition usually occurring in cases of 
chronic disease. There may be slight fever and headache without 
other symptoms. In some cases, however, the onset is sudden and 
apoplectiform in type. The patients develop hemiplegia, unconscious- 
ness, and occasionally unilateral convulsions. 

Internal or Leptomeningitis. The symptoms vary according to the 
nature of the process, its localization, and extent. The patient may 
for a few days preceding an attack complain of malaise and headache, 
then there is often a chill followed by fever, convulsions, and delirium. 
The headache becomes more intense, and frequently there is vomiting, 
sometimes without associated nausea. The headache is usually severe, 
and often localized to the frontal or occipital regions ; occasionally, 
however, it is more general. From time to time there are acute exacer- 
bations, causing the patient to cry out — the hydrocephalic cry. The 
skin is hypersesthetic ; all the sensory nerves have their functions 
increased ; there is photophobia and inability to tolerate noises. Fre- 
quently there is paresis of the vasomotors of the skin, so that localized 
cutaneous irritation, such as may be produced by drawing the end of 
a blunt object across the surface, gives rise to a persistent red mark 
(tdche cerebrate). The patient usually lies with the head drawn far back 
and the muscles of the neck tense and rigid. This, however, occurs 
only when the cervical portion of the spinal cord is also involved. It 
is an exceedingly important and an almost pathognomonic symptom. 
Any attempt to straighten the head causes intense pain. Examination 
of the eye-grounds usually shows intense congestion and more or less 
perineuritis. Sometimes there is very distinct choked disk. The 
pupils are often unequal, and strabismus and even nystagmus fre- 
quently occur. Paralysis of any of the cranial nerves indicates that 
the process is chiefly localized at the base, as in tuberculous meningitis. 
Paralysis of the oculomotor or some of its branches is exceedingly com- 
mon. The facial nerve may also be paretic. The tendon reflexes are 
usually somewhat exaggerated, muscular tone is increased, and occa- 
sionally there is distinct monoplegia or hemiplegia. Fever, headache, 
and delirium usually persist throughout the course of the disease ; and 
the former is often very high. The different forms of meningitis are 
often difficult to discriminate. By means of Quincke's lumbar puncture 
it is sometimes possible to make a bacteriological diagnosis from the fluid 
withdrawn. Meningitis due to certain pyogenic micro-organisms, such as 
the pneumococcus, staphylococcus, etc., may be suspected ; when the 



DISEASES OF THE NERVOUS SYSTEM. 1053 

fever is high there is marked retraction of the head, indicating spinal 
involvement, and the course is steadily progressive to death. Some 
other disease may often be associated with the meningitic symptoms, 
or it may have occurred previously, as pneumonia, typhoid fever, etc. 
Epidemic cerebro-spinal meningitis may simulate the symptoms of 
purulent meningitis exactly. In some cases, however, the course is 
more prolonged, and even wdien the termination is fatal there is apt to 
be a remission of longer or shorter duration. Tuberculous meningitis 
is usually characterized by the presence of paralyses of some of the 
cranial nerves, particularly those of the eye muscles, and the absence 
of symptoms of spinal involvement. This disease may run an exceed- 
ingly slow course, and the diagnosis is often for a time impossible. 
Kernig's sign is said to be pathognomonic of meningitis. It consists 
of the inability of the patient to straighten the leg when the thigh 
has been flexed upon the abdomen and the leg upon the thigh. 

Cerebral Hemorrhage (apoplexy). This is characterized by a great 
variety of symptoms, depending largely upon the location of the lesion. 
They may be divided into those of the attack and those that are perma- 
nent. The symptoms of the attack consist of prodromata — that is, head- 
ache, tendency to vertigo, a sense of fulness in the head, roaring in the 
ears, and perhaps some thickness of speech. These may pass off without 
an attack or may lead directly to it. The attack itself is usually char- 
acterized by the sudden occurrence of complete unconsciousness. The 
patient falls to the ground, and there is at first a temporary pallor. 
This is succeeded by flushing of the face, which may become almost 
purple. The pulse is full and bounding and with difficulty compress- 
ible. The breathing is stertorous, the eyes are partially opened ; the 
pupils are usually contracted and often unequal. Often there may be 
vomiting, or involuntary micturition or defecation. The limbs remain 
completely paralyzed, or in some cases there are unilateral convulsions. 
If, as is commonly the case, the hemorrhage has involved the motor 
tract, there is complete flaccid paralysis of one side, with, however, 
increased reflexes. If death does not occur in the course of the first 
twenty-four hours, the patient usually begins to shoAv signs of con- 
sciousness, and may be aroused from his comatose condition by sharp 
questioning. The patient then ma} r go into a still more deeply coma- 
tose condition, with rise of temperature, followed by death, or there 
may be no further indications of hemorrhage, and recovery may set in. 
As a rule, in those cases in which the prognosis is favorable no rise of 
temperature occurs. It may now be found that the patient has hemian- 
opsia, usually the visual fields on the same side of the lesion being 
blinded. Conjugate deviation may or may not have existed from the 
first, the patient ordinarily looking toward the sound side. If the 
speech centre has been involved, there is absolute aphasia ; but even 
when it is not directly affected partial aphasia is very common. The 
hemiplegic limbs remain paralyzed ; the others regain their power. It 
is now necessary to determine the extent of the damage and to locate 
as nearly as possible the situation of the lesion. Complete hemiplegia 
may involve the lower branch of the facial, the arm, and the leg. The 
upper branch of the facial and the muscles of the trunk commonly 



1054 SPECIAL DIAGNOSIS. 

escape, although the former may show slight paresis. Sensory disturb- 
ances may or may not be present. There is sometimes loss of all forms 
of sensation and sometimes disturbance of only the tactile or the mus- 
cular sense. Occasionally when tactile sense is preserved there may 
be loss of the stereognostic sense. Complete hemiplegia with disturb- 
ance of sensation almost invariably indicates destruction of the internal 
capsule upon the opposite side. Motor disturbances in the form of clonic 
convulsions may also occur in the paralyzed limbs, and occasionally, 
probably as the result of a double lesion, in the limbs of the sound 
side. They are commonly the result of cortical lesion, irritating in 
character, either infarction, or else some growth pressing upon and 
involving the cortex. As the case progresses there is usually more 
or less return of motor power and almost complete return of sensation. 
This may, however, be exceedingly gradual, several weeks elapsing be- 
fore the sensory disturbances have entirely disappeared. The muscles 
that remain permanently paralyzed gradually atrophy, but nearly always 
give normal qualitative electrical reactions until the muscular substance 
disappears, leaving contracted fibrous tissue. The muscles themselves 
may show early contractions, the flexors ordinarily overcoming the 
extensors. Repeated attacks of apoplexy are by no means uncommon, 
and the double lesions thus produced may give rise to very complex 
symptom-groups. (See, also, Cerebral Localization and Aphasia.) 

Cerebral Embolism and Thrombosis. This is a condition characterized 
by symptoms very similar to those of cerebral hemorrhage. Prodromal 
symptoms, in the form of headache, vertigo, weakness, and malaise, are 
often present. At times there also may be slight impairment of speech, 
or the patient may be dull and apathetic. The attack usually comes 
on more gradually than hemorrhage, although this is not invariably 
the case. In some instances consciousness is not entirely lost, and as 
a result the hemiplegia may develop before the coma. When uncon- 
sciousness does occur there is usually less congestion of the face and 
not such marked evidence of increased arterial tension as we find in 
hemorrhage. Among the other general symptoms may be mentioned 
convulsions, vomiting, and occasionally delirium. The permanent 
symptoms resemble exactly those produced by hemorrhage, but 
recovery is usually more rapid and more complete than in the former 
condition. Apoplexy occurring in children differs from that occurring 
in adults only by the fact that the initial symptoms are more severe, and 
the convulsions are frequent and may be repeated. The permanent 
symptoms differ slightly, inasmuch as aphasia rarely persists. The 
paralysis may be partial, and may in some instances be replaced by 
athetoid movements. Sensation is rarely impaired. 

Bulbar paralysis is a disease of the peripheral motor neurons arising 
in the medulla. It is characterized by the degeneration of the muscles 
of the lips, tongue, and pharynx. The course is slowly progressive. 
The earliest symptom is dysarthria, then difficulty in swallowing, 
chewing, and phonation. The face becomes expressionless, the mouth 
remains open, saliva dribbles from it, and occasionally the eyelids are 
involved and the eye remains open (logophthalmus). The cardiac 
action and respiration may be rapid. Death usually occurs as a result 



DISEASES OF THE NERVOUS SYSTEM. 1055 

of inspiration pneumonia, or exhaustion. In the variety known as 
asthenic bulbar paralysis there may be long remissions or even per- 
manent recovery. 

Encephalitis. This is a condition that rarely can be diagnosed during 
life. It may be suspected, however, if, in the course of some other 
acute infectious disease, the patient develops intense headache, severe 
delirium, and perhaps local palsies. There may be general exaggera- 
tion of all the reflexes, with ankle clonus, and usually hyperesthesia of 
the skin, and exaltation of the special senses. Examination of the 
eye-grounds usually fails to reveal optic neuritis. 

Abscess of the Brain. This is a local disease, giving rise to local 
and general symptoms. General disturbances are chiefly fever, chills, 
leukocytosis, headache, and delirium. The symptoms of focal dis- 
ease depend, of course, upon the location of the abscess. The com- 
monest seat is in the temporo-sphenoidal lobe, as a result of infection 
following ear disease. This often gives rise to mind-blindness or 
amnesia. Sometimes there are no general symptoms if the abscess is 
located in the blind regions of the brain. The focal symptoms may 
not be manifest until rupture has occurred. This often gives rise to 
an epileptiform attack. 

Tumors of the Brain. Like the preceding lesion, these give rise to 
two groups of symptoms : general, which are merely those of increased 
intracranial pressure ; or local, due to the involvement of centre and 
tracts. The general symptoms of brain tumor are (1) headache. This 
is usually very severe, of a boring character, and subject to exacer- 
bations ; (2) vomiting. This is paroxysmal, and often occurs without 
nausea ; (3) papillitis. It usually occurs early, is intense, and often 
leads rapidly to blindness. The local symptoms are, of course, numer- 
ous. Tumors in the frontal lobe give rise to none, or at most to some 
disturbance of intelligence and perhaps a tendency to make puns. 
Tumors in the motor region may cause irritative or destructive changes 
in the tissue. Irritation is manifested by local spasms, which may or 
may not be succeeded by general convulsions (Jacksonian epilepsy). 
Paralytic lesions are those of monoplegia or hemiplegia. Tumors in 
the parietal lobes may cause interference with the muscle sense or 
some disturbance of vision or speech centres, according to their situa- 
tion. Tumors in the occipital lobes usually cause mind-blindness — 
that is, inability to recognize objects, and preservation of the pupillary 
reflexes. Tumors in the different fossa of the skull often give rise to 
symptoms dependent upon pressure upon the cranial nerves. In the 
anterior fossa there may be loss of the power to smell upon one side. 
In the middle fossa the nerves chiefly affected are the optic, giving 
rise to unilateral blindness, or, if the tumor involve the chiasm, to 
bitemporal hemianopsia ; the oculomotor nerves, the abducens and 
the pathetic, giving rise to more or less complete ophthalmoplegia. 
Tumors in the posterior fossa commonly involve the facial and 
auditory nerve, and it is said that facial paralysis with nerve-deafness 
on the same side is characteristic of tumor in this situation. The 
hypoglossal nerve may also be involved. Tumors may, of course, 
grow slowly, rapidly, or cease to increase in size, and the symptoms 



1056 SPECIAL DIAGNOSIS. 

show a corresponding rate of development. In rapidly growing 
tumors apoplectiform attacks are frequent, but a certain amount of 
compensation occurs, and remissions are not uncommon. In slowly 
growing tumors the symptoms may remain apparently stationary for 
long periods. Tumors are sometimes entirely latent, and are simply 
discovered accidentally at the autopsy. 

Sclerosis of the Brain. This is usually a diffuse or a multiple lesion 
that gives rise to a great variety of symptoms, more or less indefinite 
in character. Ordinarily the lesion is congenital, or develops shortly 
after birth. The patient remains an imbecile or an idiot, and soon 
develops epileptic convulsions. If the sclerosis is more pronounced 
on one side than the other there is usually a tendency to fall toward 
the opposite side. There may be arrest in development in these limbs, 
and more or less muscular paralysis. Occasionally, apparently as a 
result of foetal thrombosis or embolism, the sclerosis may be limited 
to one portion of the brain or even to one hemisphere. In this case 
there is always arrest in the growth of the opposite side of the body. 

Hydrocephalus (chronic infantile form). This is characterized by an 
extraordinary alteration in the contour of the head, which becomes 
greatly enlarged and globular in shape, while the face remains small 
and infantile in appearance. The symptoms are sometimes exceedingly 
pronounced ; at other times entirely absent. Persons with a moderate 
degree of hydrocephalus have displayed through life a normal intelli- 
gence. In other cases the head is heavy and the muscles of the neck 
unable to support it. The child is an imbecile or an idiot, and epileptic 
convulsions are very common. Occasionally ocular symptoms may be 
present. These consist of ptosis, strabismus, or nystagmus, and some- 
times of atrophy of the optic nerve, and blindness. 

Acute Delirium. This is a disease characterized by prodromata and 
a stage of excitation, and usually terminates in death. The prodromata 
consist of disturbances of the general health, loss of appetite, and in- 
somnia. The patient is restless, anxious, and may show diminution of 
intelligence, and become more or less violent. He then rapidly 
passes into the stage of excitation, is restless, noisy, and frequently 
homicidal, shouting disconnected words or sentences, singing or shriek- 
ing. Sometimes there are delusions of persecution, and he attempts to 
escape. In addition, there are the symptoms of the so-called typhoid 
state, high fever, profound prostration, dry tongue, and rapid and weak 
pulse. The patient refuses all food, is continually active, and emaciates 
very rapidly. Among the objective symptoms are increase of the 
reflexes, narrowing of the pupils, and hyperesthesia, with more or less 
hypalgesia. From this stage the patient passes into a state of collapse, 
lies in a condition of muttering delirium, with carphology, and usually 
dies from exhaustion. 

General paralysis of the insane is a form of progressive dementia 
characterized by delusions of grandeur or states of depression associ- 
ated with exacerbations of maniacal character. There are, in addition, 
weakness and tremors of the muscles of the face, paresis of the extremi- 
ties, the Argyll-Robertson pupil, and peculiar disturbances of speech. 
It is usual to recognize three stages. The prodromal stage, character- 



DISEASES OF THE NERVOUS SYSTEM. 1057 

ized by irritability or sometimes by depression ; diminution or loss of 
the moral sense ; impaired judgment, particularly in business affairs ; 
and a tendency to extravagance and dissipation. Frequently symptoms 
associated with degeneration, such as intolerance for alcohol, intense 
egotism, etc., appear. The sexual function in this stage is often greatly 
increased. Memory fails and the intellectual capacity is considerably 
diminished. There are often slight disturbances of speech, and some- 
times paralytic pupils. Frequently there is insomnia and occasional 
attacks of migraine. In the second stage, which usually develops 
gradually, the attacks of migraine are replaced by apoplectic or epileptic 
attacks or by distinct maniacal conditions ; memory is greatly impaired, 
the intellect is considerably disturbed, the patient becoming unable to 
do easy mathematical problems, to comprehend his environment, or 
to sustain a simple conversation. Usually there are delusions of gran- 
deur, the patient believing himself rich, beautiful, successful, intelligent, 
and reiterating constantly his advantages, although from time to time 
there will be states of depression and partial recognition of the failure 
of power. In other cases, however, particularly chronic alcoholics, 
there is distinct melancholia ; the patient is hypochondriacal, or may 
have delusions of persecution, or a sense of misfortune. The disturb- 
ances of speech are characteristic ; the most common is the omission 
of syllables. This may best be tested by asking the patient to repeat 
certain words, particularly those containing a number of r ? s and l's, as 
" third riding artillery brigade," " truly rural," etc. There is marked 
tremor of the lips and of the tongue, producing a sort of ataxia in the 
speech, with the disturbance of the formation of nearly all the sounds. 
The pupillary changes are similar to those described in the prodromal 
stage, but usually are more pronounced. The extremities are weak, 
and often exhibit distinct tremors. Finally, the patient becomes com- 
pletely demented, usually lies quietly and placidly in bed, or occasion- 
ally mutters unintelligible sounds. Sensation, either as a result of 
impaired perception or because of degenerative changes in the periph- 
eral nervous system or the spinal cord, becomes greatly impaired, 
particularly the pain-sense. The patient is unable to stand, and has 
involuntary or rather unperceived micturition and defecation, and fre- 
quently develops bed-sores or cystitis. A curious and quite common 
symptom is the gnashing of the teeth, which in some cases is almost 
persistent. Death usually occurs from exhaustion. Among the less fre- 
quent symptoms are a curious unsteadiness of gait, exaggeration of the 
reflexes, rapid diminution in weight, particularly in the last two stages. 
Epilepsy. This is a condition characterized by attacks of clonic 
convulsions, associated with loss of consciousness and usually some 
impairment of intelligence. In the characteristic epileptic fit we can 
usually distinguish three stages : the prodroma, the attack, and the 
postepileptic stage. In the prodromal stage aura? are frequently 
present. These may be of the most varying character. A patient 
may either have a curious sensation in the epigastrium, paresthesia 
in a limb, and the subjective sensation of movement, or disturbance of 
the special senses, particularly an unpleasant odor or a whirring sound. 
Sometimes the sensations are painful or distressing, as a sense of con- 

67 



1058 SPECIAL DIAGNOSIS. 

striction about the throat. At other times there is giddiness, vertigo, 
or nausea, or the recurrence of some particular idea. Occasionally the 
aurse consist of some imperative movement, such as whirling about, 
running, or jumping. At the commencement of the attack there is 
usually a cry — the epileptic cry. Ordinarily this is a curious sort of 
gasping, due to the forcible contraction of the thorax and partial closure 
of the glottis. In some cases, however, it may be a loud shriek. The 
patient then falls to the ground, and the convulsive movements com- 
mence. These are rarely of equal vigor on both sides ; the head and 
eyes show conjugate deviation ; the face is bluish and pallid ; the mouth 
is filled with frothy fluid, which is often blood-stained, on account of 
biting the tongue ; the limbs may be extended or flexed in tonic con- 
traction. This is soon replaced by a violent to-and-fro tremor. The 
patient is completely unconscious, and may, in falling, cause himself 
serious injury. There is no conjunctival reflex, the pupils are widely 
dilated ; frequently the urine is passed during the attack, and there is 
occasionally profuse sweating. Toward the end the convulsions become 
less frequent. Respiration is re-established ; at first irregular, then gradu- 
ally it becomes more aud more steady. The cyanosis disappears, and 
the patient usually passes into a profound sleep. This may last several 
hours, and he then awakes, feeling dull and fatigued, but otherwise 
normal. At other times, immediately after the attack, there is vomit- 
ing or nausea, and sometimes a feeling of excessive hunger. He may 
become maniacal, usually with homicidal mania, or the postepileptic 
stage may be manifested by nothing more serious than some imperative 
movement, such as running or shouting. The convulsive stage may be 
replaced by purely sensory phenomena, without .complete loss of con- 
sciousness, or there may be merely a fine tremor, or the patient may 
simply run or be otherwise violent, while wholly unconscious. 

Petit Mai. In this condition the loss of consciousness is so transitory 
and the motor symptoms are so slight that its nature often escapes 
detection. The patient, if talking, will suddenly stop for a moment ; 
there is a peculiar rigidity of the expression and perhaps slight sway- 
ing. This will disappear almost immediately, and the patient will 
resume the conversation. Sometimes after these attacks there will be 
a feeling of drowsiness for a short period. Aurse may be present in the 
form of giddiness or twitching of the limb. The attack may also occa- 
sionally be ushered in with a scream or a peculiar gasping expiration. 
Immediately after the attack automatic movements may be performed. 
Attacks of petit mal often occur during sleep, and the only symptoms 
then that point to the existence of the disease are a feeling of heaviness 
in the morning, perhaps a sore and bitten tongue, and nocturnal enuresis. 

Focal epilepsy (Jacksonian epilepsy). This form resembles general 
epilepsy, with the difference that the motor or the sensory disturbances 
always commence in the same part of the body, and from this part 
gradually extend until they become general. Thus, the thumb may 
first be affected, showing a tonic and then a clonic spasm ; then the 
hand, the arm, the whole of that side, or both sides ; or the disturbance 
may commence in the foot. The disease almost invariably indicates 
the existence of a focal lesion in the brain. 



DISEASES OF THE NEEVOUS SYSTEM. 1059 

General Symptoms in Epilepsy. Epileptics are usually dull, apathetic, 
having a tendency to excess in eating. An excess of indican is often 
present in the urine. Often there is distinct mental impairment, or, 
when the disease occurs early in life, there may be congenital imbe- 
cility or idiocy. The temper of epileptics is usually irritable, and they 
are likely to commit acts of violence. 

Migraine (hemicrania). This is a disease characterized by parox- 
ysmal attacks of headache associated with nausea and vomiting, and 
frequently with disturbances of the special senses. The attacks are 
usually followed by prolonged sleep. The headache is peculiar, in that 
it commences slowly as a dull but severe pain that gradually increases 
in intensity, with occasional exacerbations or throbbing, and is limited 
to one side of the head. Occasionally, however, it is bilateral, but is 
then usually unequal. At the same time the patient experiences a 
sensation of intense nausea that may be followed by vomiting. The 
special senses are affected in various ways. There may be photophobia, 
hvperacusis, and occasionally the appearance of peculiar scotomata, 
which commence as a bright spot that spreads, the outer edge being of 
an irregular, jagged character, and finally disappears at the periphery 
of the field of vision. New lines constantly form at the centre, and 
follow those first appearing. Sometimes the patient complains of dim- 
ness of vision, and this may affect only part of the visual field. Occa- 
sionally there is temporary aphasia, particularly if the pain occurs in 
the left side of the head. In addition, the patients may observe vaso- 
motor symptoms, paresthesia, or occasionally stiffness or spasms in the 
limb. The paroxysm usually terminates in sleep, which may be pro- 
longed, and when the patient awakens all symptoms have disappeared. 
Sometimes there is a severe attack of polyuria. 

Meniere y s Disease. This is characterized by attacks of vertigo, asso- 
ciated with nausea. The attack usually begins with tinnitus, then 
intense vertigo, which may come on so suddenly that the patient falls 
to the ground, or else he is obliged to lie down, and remain in this 
position until the attack is over. 

Hysteria is a disease due to disturbance of the self-control, producing 
a curious complex of symptoms that appear to be the result of imitation 
or of a desire to attract attention or sympathy, associated with certain 
disturbances of the special senses and of sensation. The psychical symp- 
toms are a certain tendency to self-consciousness, so that the patient is 
anxious to describe his or her sufferings to surrounding persons ; is in 
the habit of performing ludicrous or startling acts for the purpose of 
attracting attention ; is emotional, weeping or laughing readily, and 
is often irritable and suspicious. Among the sensory symptoms are 
areas of tactile anaesthesia or analgesia. These may involve exactly 
one -half of the body, including the accessible mucous membranes, or 
they may be symmetrical in distribution on both sides of the median 
line, and often form geometrical figures. These are not the result 
apparently of simulation on the part of the patient, because they remain 
unchanged for a number of days. Tenderness — that is, hyperalgesia 
— may be present over the ovaries and the spine. The areas of anaes- 
thesia may be transferred from one part of the body to the other, 



1060 SPECIAL DIAGNOSIS. 

either spontaneously or as a result of suggestion. The latter is most 
effectual when the transfer is made by means of a magnet or metals. 

The special senses may have their function exalted, so that the 
patients have an extraordinary acuteness of smell or hearing, or find 
it difficult to endure strong lights. 

Depression of the function of the special senses is perhaps more 
common, particularly loss of the sense of smell and taste. Hysterical 
deafness is exceedingly rare. Hysterical blindness not infrequently 
occurs, is characterized by widely dilated pupils, that usually react 
to light, and, of course, by normal eye-grounds. The hysterical stigmata 
associated with the eye are of great importance, partly on account of 
their peculiarities, partly on account of their persistence. The most fre- 
quent is simple contraction of the formed field. This, however, occurs in 
other conditions, and is, therefore, not as characteristic as contraction of 
the formed field with inversion of the color field — that is to say, a red 
object will be seen further from the central visual point than a blue one. 
Monocular diplopia, in the absence of structural defect in the eyeball, is 
pathognomonic of hysteria. In rare cases three images may be perceived. 

The motor symptoms are paresis, or occasionally complete paralysis. 
The commonest form of this is hysterical aphonia, in which the patients 
are unable to contract the vocal cords for the purpose of producing 
sound, but may be perfectly able to cough or perform any other func- 
tion with them. In these cases speech usually returns suddenly under 
the influence of a strong emotion or suggestion. The paralysis in other 
parts of the body occurs in imitation of some form of organic disease. 
Thus there may be paraplegia, hemiplegia, or monoplegia. Loss of 
power is rarely complete, and occasionally patients move the limbs 
when they believe themselves unobserved. The electrical reactions 
remain normal, although the degree of resistance in the skin may be 
greatly increased. The reflexes are exaggerated, especially those due 
to cutaneous irritations, such as the plantar reflex, but ankle clonus 
does not occur. The gait may be staggering, imitating cerebellar 
ataxia or the ataxia due to intoxication ; sometimes there are tremors, 
coarse and irregular, and rarely constant. In some cases of hysteria 
actual contractures of the muscles occur, indicating the existence of 
trophic disorders. Spasmodic contractions sometimes occur in the 
muscles of the abdomen, giving rise to an apparent or hysterical 
abdominal tumor. Actual trophic changes may also occur in hys- 
terical patients, but these are rare in this country. There may be 
hemorrhages into or from the skin, particularly from the forehead, 
palms of the hands, and the soles of the feet (stigmata of the passion), 
or there may be localized areas of gangrene in the skin. 

The attack (crise hysterique) may be divided into the prodromal period 
and the convulsive. The aurse consist of a variety of sensory disturb- 
ances, of which the most common is the sensation of a ball rising in 
the throat (globus hystericus). The patient may also have a sensation 
of heat or cold, or moisture of the skin, or various painful impressions. 
Occasionally the tenderness over the ovary is greatly increased (ovaria), 
and the attack may be precipitated by pressure in this region. It is 
impossible to describe all the movements that occur in the grande crise. 



DISEASES OF THE NERVOUS SYSTEM. 1061 

The convulsion may be tonic or clonic. The patient may assume the 
most extraordinary positions. Among the most characteristic is opis- 
thotonos, in which the heels and the back of the head rest upon the 
floor or bed, while the body forms an arch ; or the patient may assume 
attitudes that suggest or are characteristic of mirth, sorrow, fear, pas- 
sion, etc. Consciousness is rarely entirely lost, although there may be 
subsequently total amnesia for the period of the attack, and, no matter 
how violent the movements of the patient, injury to any part never 
occurs. Gradually the movements become less violent, the patient be- 
comes quiet, and consciousness returns. During the attack the pupils 
are usually dilated, the reflexes may be increased, and respirations are 
commonly extremely rapid, in one case that I observed they reached 
100 per minute. Occasionally the attack may be cut short by pressure 
upon one of the hysterogenic zones. After the attack the patient may 
be perfectly normal. At times there may be persistent, curious, per- 
verse tendencies, such as unwillingness to eat, or, at least, a simulation 
of fasting. 

Neurasthenia is a disease characterized by an exceedingly complex 
symptomatology. The symptoms may be divided into the general and 
special groups : the former including those common to all forms of 
neurasthenia, the latter those associated particularly with subjective 
and objective functional disturbance of the various organs. The mental 
symptoms are various. The patients are usually querulous, depressed, 
and hypochondriacal. They are very irritable, but incapable of 
prolonged emotional exaltation. They find difficulty in concentrat- 
ing their attention, particularly upon those subjects with which they 
have previously been familiar. Memory is impaired and the intellec- 
tual capacities apparently diminished. It must be remembered, how- 
ever, that careful testing of the memory or judgment rarely shows 
that it is seriously affected. An important symptom is the insomnia. 
This may be of all varieties, but ordinarily the patient, after sleeping 
in the early part of the night, Avill awaken and be unable to sleep again 
for some hours. The statements by the patients in regard to this symp- 
tom are very unreliable. Frequently they complain of unpleasant or 
frightful dreams when they actually have slept. Among the sensory 
symptoms the most important is headache. This is of a peculiar but 
almost typical form. The patient complains of a heavy, dull feeling, 
as if wearing some heavy object, the usual simile being a lead helmet. 
Occasionally the pain is localized ; sometimes to the occipital region 
and sometimes to a circumscribed area, the latter usually the result of 
suggestion. Another symptom that is very common is pain in the 
back. This is usually felt in the neck or the lumbar and sacral region ; 
it is of a dull, persistent character, and may be associated with points of 
tenderness over the spine. Occasionally there are disturbances of the 
special senses. The patient may complain of inability to see sharply, 
or there may be muscse volitantes. At other times he will fail to hear 
distinctly or may complain of roaring or tinnitus. Actual diminution 
of the visual power or of the sense of hearing does not occur. The 
patients may complain, however, of paresthesias in the limbs and of 
various symptoms usually the result of suggestion. Sensation is other- 



1062 SPECIAL DIAGNOSIS. 

wise normal. There is usually a general decrease in muscular power. 
Sometimes this may be preserved for short periods of activity, but 
fatigue, as a rule, comes on very rapidly. At other times it is impos- 
sible for the patient to exert the amount of force that would be normal 
for his muscular development. Occasionally this weakness is localized 
to one limb or side of the body. When the patient is directed to hold 
a limb rigid or to extend the fingers forcibly a fine tremor of the 
extremities occurs. This may be persistent or readily exhausted ; in 
addition, fibrillary twitchings of the muscles not infrequently occur. 
The tendon reflexes are generally exaggerated. Ankle clonus, however, 
excepting the form spoken of as pseudoclonus, is exceedingly un- 
common. Absence of the knee-jerk does not occur in neurasthenia. 
The cutaneous reflexes are sometimes greatly exaggerated, sometimes 
depressed. Vasomotor symptoms are very common. The patient 
flushes easily, and there is often dermographia ; he complains of palpi- 
tation and occasionally of irregularity of the heart's action. Often 
perspiration is produced by slight exertion. 

In addition to these symptoms, the neurasthenic may complain of 
various local disorders of the nervous system ; he usually suspects that 
he has locomotor ataxia, and he will probably have learned the symp- 
toms of this condition sufficiently well to imitate them more or less 
accurately, or he may believe himself suffering from general paresis or 
brain tumor, or any other condition with which he may be familiar. 
From general paresis the diagnosis is sometimes quite difficult unless the 
Argyll-Robertson pupil, which never occurs in neurasthenia, is present. 
Another common form is gastro-intestinal neurasthenia. The patient 
may complain of excessive acidity, and, in fact, vomit from time to 
time masses of acid material, or there may be difficulty with digestion 
and hypochlorhydria or anacidity. Constipation is an exceedingly fre- 
quent symptom. From time to time the patient may also evacuate 
large quantities of mucus, and sometimes there may be persistent 
mucous diarrhoea. This is one of the most intractable forms of the 
disease. Finally, the patient may be a sexual neurasthenic and be- 
lieve himself to be suffering from organic or functional disease of the 
genital organs. To this variety is usually, but I believe incorrectly, 
reckoned the various types of sexual perversion. The degree of neu- 
rasthenia is spoken of as mild or severe, according as the symptoms 
are slight or pronounced. 



INDEX. 



A BASIA, 74 

lV Abdomen, aspiration of, 358 
color of, 727 
enlargement of, general, 729 

local, 733 
inspection of, 727 
markings on, 727 
palpation and percussion of, 735 
retraction of, 735 
shape of, 729 . 
topography of, 725 
Abscess of brain, 1055 

fecal, 743 

of kidney, 966 

pelvic, 744 

pericecal, 743 

perinephritic, 913 

in precordial region, 584 

retropharyngeal, 717 

subdiaphragmatic, 753, 764 
Acetonemia, 958 
Acetonuria, 936 

Achromia of red corpuscles, 375 
Acroparesthesia, 1043 
Acne, 143 
Acromegalia, 169 
Actinomyces, 352 

in sputum, 536 
Actinomycosis, 350 

of mouth, 694 

pulmonic type of, 351 
Addison's disease, 124 
Adenoid vegetations in nasopharynx, 714 
Adherent pericardium, 648 
JEgophony, 513 

in pleurisy, 571 
JEsthesiometer, 974 
Age in the etiology of disease, 24 
Ague, dumb, 285 
Albumin in urine, tests for, 921 

quantitative estimation of, 926 
Albuminuria, 927 

in renal calculus, 905 
Albumosuria, 929 
Alexia, 1000 
Alkaptonuria, 937 
Allochiria, 974 
Alveolar cells in sputum, 523 
Amaurosis, uremic, 966 
Amnesia, 1010 
Amoeba dysenterie or coli, 344 

in feces, 830 

in pus, 363 

in sputum, 528 



Amoebic dysentery, 342 
Amyloid degeneration of kidney, 968 
Anemia, 389, 401 
blood in, 394 
classification of, 390 
from disease, 391 
fever in, 209 
in gastric disease, 794 
from hemorrhage, 391 
local, 402 

from malnutrition, 392 
murmurs in, arterial, 641 
cardiac, 637 
venous, 641 
in nephritis, 959 
neuralgia in, 48 
parasitic, 391 

pernicious or idiopathic, 393 
in phthisis, 558 
splenic enlargement in, 392 
symptoms of, 370 
toxic, 390 
Anesthesia, 972 

dolorosa, 973 
Analgesia, 972 
Anarthria, 1006 
Anasarca, 153 
Aneurism, 674 
of heart, 656 
thoracic, 674 

diagnosis of, 681 
hemorrhage in, 467 
pain in, 584 
physical signs of, 678 
sphygmogram in, 612 
Angina Ludovici, 706, 717 
pectoris, 585 

in aortic regurgitation, 657 
arterial tension in, 606 
in coronary artery disease, 654 
Angle of Ludwig, 472 
Ankle clonus, 988 
Ankylostomum duodenale, 838 
Anorexia, 772, 799 
Anosmia, 419 
Anthracosis, 327 
Anthrax, 277 

bacillus of, 278 

distinguished from carbuncle, 279 
intestinal form of, 277 
wool- sorter's type of, 278 
Antrum, abscess of, 429 
Aorta, aneurism of, 674. See also Aneu- 
rism. 



1064 



INDEX. 



Aorta, atheroma of, murmurs in, 637 
pain in, 584 
pulsation of, 596 
Aortic area, 632 

obstruction, 659 

distinguished from atheroma of 

aorta, 639 
thrill in, 603 
regurgitation, 657 

presystolic murmur in, 665 
pulsation in, distinguished from 

aneurism, 683 
pulse in, 639 
sphygmogram in, 612 
thrill in, 603 
Apex-beat. See Heart, impulse of. 
Aphasia, 1000 
Aphonia, hysterical, 1060 

in pericardial effusion, 645 
Apoplexy, 1053 

relation of arterio-sclerosis to, 673 
Appendicitis, 738 

abscess formation in, 741 
catarrhal, 738 
decubitus in, 69 

distinguished from acute intestinal 
obstruction, 851 
from hip-joint disease, 742 
from perinephritic abscess, 743 
from typhoid fever, 302, 740 
gangrenous, 742 
pain in, 818 
palpation in, 737 
perforating, 741 

distinguished from acute tubercu- 
lous peritonitis, 743, 755 
recurrent, 740 
tuberculous, 755 
Appetite, alteration of, 772, 799 
Apraxia, 1006 
Aprosexia, 715 
Arcus senilis, 96 
Argyria, 126 
Arrhythmia, 587 

in auto-intoxication, 203, 211 
Arsenic-poisoning, 216 
Arteries, murmurs in, in arterial sclerosis, 
673 
palpation of, 605 
pulsation of, visible, 596 

in aortic regurgitation, 658 
sclerosis of, 672 
tension of, 606 
Arterio-capillary fibrosis, 672 

pulsation of arteries in, 598 

Arthritis, gonorrheal, 178 

rheumatoid, 185 

hand in, 113 

tuberculous, 178 

Ascaris lumbricoides, 833 

symptoms of, 815 
Ascites, 729 

character of fluid in, 730 
distinguished from enlargement of 
liver, 871 
from hydronephrosis, 912 



Aspiration, technique of, 357 
Astasia, 74 
Asthma, 459 

causes of, 460 

decubitus in, 69 

in nasal disease, 420 

sputum of, 524 
Atavism, 29 
Ataxia, 979 
Atelectasis, 548 
Atheroma of arteries, 672 

murmurs in, 641 
Athetosis, 983 
Auscultation of chest, 502 

sounds in health, 503, 505 

of voice, 512 
Auto-intoxication, 760 



BACELLTS sign of empyema, 572 
Bacilli of Booker, 836 
Bacillus of anthrax, 278 
of cholera, 338 
coli communis, 363, 835 
of diphtheria, 333 
general characteristics of, 221 
of influenza, 536 
of leprosy, 349 
mallei, 336 

mucous capsulatus, 535 
of pertussis, 536 
smegmse, 532 

in gangrene of lung, 530 
of syphilis, 363 
of tetanus, 353 
of tuberculosis, 530, 836 
of typhoid fever, 298 
of yellow fever, 305 
Backache, 57 

in infectious fevers, 201 
Bacteria, general characteristics of, 220 
Bacteriological diagnosis, 229 
methods, 230 

apparatus, 231 
collection of material, 232 
cover-slip preparations, 244 
culture media, 242 
examination of blood, 232 
hanging-drop preparations, 241 
identification of organisms, 245 
inoculation of animals, 244 
plate culture, 243 
smear culture, 244 
staining, 240 

of capsule, 535 
of tubercle bacillus, 532 
sterilization, 231 
Bacteriuria, 948 
Bamberger's sign of pericardial effusion, 

648 
Baruch's sign of typhoid fever, 301 
Belching, 802 
Bell tympany in chest, 412 
Beri-beri, 1046 

oedema in, 152, 153 
Bile in urine, test for, 936 



INDEX. 



1065 



Bile-ducts, cancer of, distinguished from 
hepatic cancer, 882 

inflammation of, 885 

obstruction of by gallstones, 886 
Biliousness, 855 

bad taste in, 764 
Black tongue, 696 
Blasts, 375 
Blepharospasm, 92 
Blood, alkalinity of, 386 

bacteriological examination of, 232 

color index of, 385 

counting the corpuscles of, 376 

cover-slip preparations of, 372 

in gastric contents, test for, 782 

haemoglobin of, 384 

leucocytes of, 379 

parasites in, 388 

physical appearance of, 371 

pigment in, 386 

pressure of, 414 

red corpuscles of, 375 
number of, 379 

serum as culture media, 242 

specific gravity of, 387 

staining of, 373 

in stools, 820 

in urine, 928, 940 
Boils in diabetes, 934 
Bones, the, 169 

in osteitis deformans, 170 

in rickets, 172 
Bothriocephalus latus, 833 

symptoms of, 814 
Boulimia, 772 
Bradycardia, 609 

in jaundice, 861 

in typhus fever, 249 
Bradylalia, 1006 
Brain, abscess of, 1055 

general symptoms of disease of, 1024 

sclerosis of, 1056 

tumors of, 1055 

choked disk in, 100 
Brawny induration, 157 
Breath, fetor of, 687, 708 _ 
Breathing. See also Respiration. 

amphoric, 508 

bronchial, 503, 507 

in pleural effusion, 571 

broncho-vesicular, 504, 509 

cavernous, 508 

jerking inspiration in, 506 

prolonged expiration in, 506 

tubular, 508 

vesicular, 503 

exaggerated, 505 
feeble or absent, 505 
Broadbent's sign of adherent pericardium, 
596 
rone 
Bronchiectasis, 566 

distinguished from phthisis, 567 
Bronchitis, acute, 542 

diagnosis of, 543 

capillary, 545 



Bronchitis, chronic, 544 

fibrinous coagula in, 524 

lithsemic, 856 

plastic, 546 

putrid, 547 
Bronchophony, 513 
Bronchorrhoea, 545 
Bronzing of skin, 124 
Brown-Sequard's syndrome, 1025 
Bulbar paralysis, 1054, 1056 



CAECUM, abscess about, 743 
inflammation of, 742 
Cachexia, cancerous, 412 
in gastric cancer, 810 
malarial, 289 
varieties of, 67 
Calculus, biliary, 885 

renal, 902 
Cancer. See Carcinoma. 
Cantering rhythm of heart, 627 
Capillary pulse, 598, 659 
Caput Medusse, 728, 877 
Carbuncle in diabetes, 934 

distinguished from anthrax, 279 
Carcinoma, cachexia of, 412 
fascies of, 81 
gastric, 808 

pain in, 771 

supraclavicular glands in, 159 
general symptoms of, 411 
of larynx, 441 
of lung, 567 

haemoptysis in, 467 
of oesophagus, 722 
of peritoneum, 754 
of skin, 158 
Cardialgia, 770 

Cardio-hepatic triangle, 615, 646 
Carreau, 736, 758 
Case-records, 22, 536 
Casts in urine, 941 

in renal calculus, 905 
without nephritis, 944 
Cataract, 99 
Catarrh, nasal, 427. See also Rhinitis. 

suffocative, 545 
Catarrhe sec, 544 
Cavities, pulmonary, 514 

bronchophony in, 413 
distinguished from pneumotho- 
rax, 578 
physical signs of, 514 
Cercomonas intestinalis, 831 
Cerebellar gait, 73 
Cerebellum, symptoms of affections of, 

1020 
Cerebral localization, 1011 
basal centres, 1018 
cortical, 1015 
medullary, 1019 
hemorrhage, 1053 
thrombosis and embolism, 1054 
Cerebro-spinal fever. See Meningitis. 
Chalicosis, 551 



1066 



INDEX. 



Charcot-Leyden crystals in nasal discharge, 
426 
in sputum, 526, 546 
Chest in adenoid disease, 715 

angles of, 471 

auscultation of, 502 

barrel-shaped, 477 

bilateral diminution in size of, 480 
enlargement of, 477 

in chronic interstitial pneumonia, 550 
pleural effusion, 576 

counting the ribs of, 472 

deficient expansion of, 487 

deformities of, 483 

fluoroscopic examination of, 488 

fluctuation in, 492 

inspection of, 473 

local changes in size and shape of, 485 

mensuration of, 515 

movements of, 476 
in disease, 486 

palpation of, 490 

percussion of, 492 

phthisical, 480 

regions and landmarks of, 471 

respiratory capacity of, 516 

rhachitic, 172, 480 

shape of normal, 475 

topographical anatomy of, 472 

transverse groove in, 483 

unilateral changes in shape of, 583 
Cheyne-Stokes respiration, 487 
Chickenpox, 253 
Chills, 191 

malarial, 280 
Chin-jerk, 985 
Chlorosis, 392 
Choked disk, 100 
Cholangitis, 862, 885 
Cholecystitis, 888 
Cholera, Asiatic, 336 

diagnosis of, 338 
spirillum of, 338 

fascies in, 81, 337 

infantum, 839 

bacilli of Booker in, 836 

morbus, 839 

nostras, 840 

spirillum of, 835 
Cholesterin crystals in pus, 363 

in sputum, 327 

in urine, 954 
Choluria, 935 
Chorea, 1039 

as a sequel to rheumatism, 181 

in heart disease, 589 

movements in, 983 
Choroiditis, 100 

Chvostek's sign of tetany, 985, 1041 
Chyluria, 948 

Claudication, intermittent, 979 
Clonic spasms, 982 
Clonus, ankle, 988 

patellar, 987 

wrist, 986 
Clubbed fingers in thoracic aneurism, 677 



Coin test in pneumothorax, 577 
Colic, hepatic, 817, 885 

intestinal, 816 

lead, 817 

renal, 817, 902 

uterine, 562 
Colitis, chronic ulcerative, 841 
Collapse, 65 

Colon, dilatation of, 732, 824 
Color index of blood, 385 
Coma, diabetic, 958 

in heart disease, 589 

urasmic, 956 
Comma bacillus, 338 
Congestion. See Hyperemia, 402. 
Conjunctiva, the, 96 
Constipation, 822 

Consumption. See Tuberculosis, pulmon- 
ary, 555. 

galloping, 552 
Convulsions, 983 

in heart disease, 589 

ursemic, 956 
Coprolalia, 1040 
Cor bovinum, 657 
Cornea in general diagnosis, 96 
Coronary arteries, disease of, 653 
Corrigan's pulse, 658 
Coryza, acute, 427 

syphilitic, 429 
Costal angle in rickets, 481 
Cough in aneurism of aorta, 676 

in bronchiectasis, 566 

in capillary bronchitis, 546 

characteristics of, 465 

in chronic bronchitis, 544 

dry, 465 

in gastric disease, 773 

in heart disease, 588 

laryngeal, 435 

in mediastinal disease, 684 

moist, 465 

in nasal disease, 420 

nervous, 436 

in pertussis, 466 

in phthisis, 560 

in pleurisy, 575 

of puberty, 465 

in pulmonary affections, 464 

reflex and central, 464 
Coxalgia distinguished from appendicitis, 

743 
Cracked-pot sound, 501 

in pneumothorax, 577 
Cramps in uraemia, 957 
Cranial nerves, location of nuclei of, 1020 

symptoms of affections of, 1025 
Craniotabes, 87 

Cranium, auscultation and percussion of, 87 
Crepitation, 510 
Cretins, facial appearance of, 82 
Crises of pain, 44 

in tabes dorsalis, 45, 800 
Croup, diagnosis of, 442, 443 
Culture media, 242 
Curschman's spirals, 525, 546 



INDEX. 



1067 



Cyanosis, 122 

in capillary bronchitis, 546 

in emphysema, 664 
Cylindroids, 945 
Cyrtometer, 515 
Cysticercus of skin, 158 
Cystin in urine, 953 
Cysts, hydatid, 366 

of kidney, 367 

ovarian, 367 

pancreatic, 367 



DEAF-MUTISM, hysterical, 109 
Deafness in adenoid disease, 714 
hysterical, 109 
in nasal affections, 420 
nervous, 108 
Decubitus, 68 

(abed-sore), 409, 1007 
Degeneration, fatty, amyloid, etc., 410 
Delirium, 1010 
acute, 1056 
in uraemia, 956 
Delusions, 1011 
Dengue, 267 

Dental arch in thumb-sucking, 687 
Dermatitis distinguished from erysipelas, 

311 
Diabetes insipidus, 916 
mellitus, 933 

acetonemia in, 958 
asthma in, 461 
bronzing in, 126 
neuralgia in, 48 
Diaceturia, 936 
Diagnosis, bacteriological, 229 

conditions rendering it impossible, 19 
data upon which based, 18 
Diaphragm, movements of, 476 
paralysis of, 461 
phenomenon of Litten, 477 
Diarrhoea, catarrhal, 819 
chronic, 822 
in gastric disease, 773 
membranous, 822 
nervous, 821 
stools in, 820 
uraemic, 957, 965 
Diatheses, varieties of, 66 
Diazo-reaction in typhoid fever, 294 
Dietl's crises, 908 
Diphtheria, 330 
bacillus of, 333 
diagnosis of, 333 
distinguished from scarlet fever, 260 

from tonsillitis, 713 
false membrane in, 332 
heart in, 333 
laryngeal stenosis in, 332 
sequelae of, 333 
uraemia in, 332 
Diplococcus intracellularis meningitidis, 
329 
pneumoniae. See Micrococcus Lanceo- 
latus. 



Diplophonia, 433 

Diplopia, 94 

Dipping in abdominal palpation, 730 

Distoma hepaticum, 833 

Dropsy. See (Edema. 

ovarian, 745 
Drowsiness in dyspepsia, 773 
Dulness on percussion, 496 
Duodenal catarrh, 839 

ulcer, 841 
Dupuytren's contraction, 115 
Dysentery, amoeba of, 344 

amoebic or tropical, 342 

catarrhal, 341 

diphtheritic and gangrenous, 345 
Dyspepsia, atonic, 803 

flatulent, 804 

in heart disease, 589 

nervous, 803 

reflex, 805 
Dysphagia, 435 

in aneurism of aorta, 720 

in disease of larynx, 430 
of pharynx, 708 
of oesophagus, 721 

from foreign body in oesophagus, 722 

mediastinal tumor, 720 

from paralysis of oesophagus, 724 

in pericardial effusion, 645 

from pressure on oesophagus, 720 
Dysphasia, 1006 
Dysphonia, 432 
Dyspnoea in adenoid disease, 716 

in aortic aneurism, 677 

in asthma, 459 

in capillary bronchitis, 545 

causes of, 456 

dyspeptic, 463 

in emphysema, 564 

expiratory, 435, 464 

in gastric disease, 773 

in heart disease, 588 

inspiratory, 434 

in laryngeal disease, 433 

in mediastinal tumor, 684 

in nephritis, 962 

in obstruction of trachea or bronchi, 
456 _ 

in pericardial effusion, 645 

in pharyngeal disease, 708 

in phthisis, 560 

rate of respiration in, 463 

in retropharyngeal abscesses, 717 

uraemic, 957, 965 _ 
Dystrophies of connective tissue, 156 

muscular, 163 



EAR-cough, 465 
discharge from, 107 
haematoma of, 107 
tophi in, 107 
Echolalia, 1006 
Eczema distinguished from chickenpox, 

255 
Elastic fibres in sputum, 523 



1068 



INDEX. 



Electrical diagnosis, 991 

Elephantiasis, 162 

Embolism, in aortic obstruction, 659 

in arterio-sclerosis, 403 

capillary, 404 

fat and air,* 404 

in malignant endocarditis, 651 

of mesenteric arteries, 815 

pulmonary, 541 
Embryocardia, 627 

in dilatation, 672 
Emphysema, 564 

atrophic, 566 

barrel-shaped chest in, 479 

breath-sounds in, 505 

distinguished from pneumothorax, 578 

interlobular, 566 

physical signs of, 565 

subcutaneous, 155, 719 
Emprosthotonos, 70 
Empyema, 572 

necessitatis, 572 

pulsating, 574 

distinguished from aneurism, 683 
Encephalitis, 1055 
Endocarditis, 650 

chronic, 653 

malignant, 651 

from pneumococcus infection, 318 

in rheumatic fever, 180 

in septicaemia, 227 

simple, 650 
Enophthalmos, 92 
Enteralgia, 816 
Enteritis, membranous, 822 
Entero-colitis, 840 
Enteroptosis, 748 
Enuresis in adenoid disease, 715 
Eosinophilia, 382 
Ephemeral fever, 212 
Epiglottis, inflammation of, 435 
Epilepsy, 1058 

focal or Jacksonian, 982, 1059 
Epistaxis, 426 
Ergotism, 215 
Eructations, 802 
Eruption in measles, 261 

in pharynx, 709 

in scarlet fever, 259 

in syphilis, 269 

in typhoid fever, 296 

in typhus fever, 248 

in varicella, 254 

in variola, 251 
Erysipelas, 309 
Erythema, 135 

of infectious diseases, 139 

medicinal, 139 

multiforme, 137 

nodosum, 138 

non-contagious, causes of, 136 
Erythromelalgia, 115 
Exophthalmic goitre, 88 

pulse in, 608 
Exophthalmos, 92 
Exploratory puncture. See Aspiration. 



Exudations, 360 

chylous, 365 

hemorrhagic, 364 

purulent, 360 

seropurulent, 364 

serous, 365 
Eye, affections of muscles of, 92 

in scurvy, 188 
Eyelids, oedema of, 91 



FACE in acromegalia, 169 
in adenoid disease, 82, 714 

in erysipelas, 310 

hemiatrophy of, 83 

in hereditary syphilis, 82 

in hydrocephalus, 82 

in nervous diseases, 82 

in osteitis deformans, 170 

in peritonitis, 751 

in scurvy, 188 

in tetanus, 352 

in uraemia, 959 

in yellow fever, 304 
Family relations in the etiology of disease, 

26,27 
Farcy, 335. See also Glanders. 
Fascies of various diseases, 81 
Fat in stools in pancreatic disease, 894 

in urine, 947 
Fauces, examination of, 708 
Fecal abscess, 743 

impaction, 737, 824 

epigastric pulsation in, 597 
Feces, 825 

bacteria in, 835 

blood in, 827,829 

chemical examination of, 836 

gallstone in, 827 

microscopical examination of, 828 

protozoa in, 830 

vermes in, 831 
Feigned disease, detection of, 33. See also 

Pain, Simulated. 
Festination, 1040 
Fever, arterial, tension in, 199 

aseptic, 209 

ataxic state in, 200 

in auto-intoxication, 211 

in carcinoma, 228 

cerebral symptoms in, 199 

cerebro-spinal, 326 

clinical causes of, 203 

course and stages of, 196, 204 

daily range of, 198 

defervescence of, mode of, 197, 204 

eruptive, 247 

glandular, 265 

hepatic intermitting, 206 

influence of age on, 204 

intermittent, 280 
in phthisis, 558 

in intoxication, 209 

malarial, 279 

Malta, 305 

miliary, 272 



INDEX. 



1069 



Fever, in morphinism, 212 

onset, mode of, 197 

pathology of, 191 

in phthisis, 558 

pulse-rate in, 199, 211 

in reaction from apoplexy, 202 

recrudescence of, 198 

relapsing, 274 

renal, paroxysmal, 905 

respiration in, 199, 211 

rheumatic, 178 

scarlet, 255 

in septicemia, 210 

simple continued, 212 

sudden fall of, 205 
onset of, 204 

in sunstroke, 211 

in suppuration, 408 

symptoms of, 198 

in syphilis, 206, 229 

tongue in, 701 

in trichinosis, 354 

in tuberculosis, 205 

types of, 195 

typhoid, 289 

in typhoid fever, 204 

typhoid state in, 199 

typhus, 247 

urinary intermitting, 206 

yellow, 303 
Fibrinous coagula in sputum, 524 
Fibroid change in tissues, 411 

tumors of uterus, 745 
Filaria sanguinis hominis, 388 

in urine, 948 
Fits, 64 

Flagellse, staining of, 158 
Flat-foot, pain in, 54 
Flatulency, 769 

in diarrhoea, 821 
Flint, murmur of, 658 
Fluctuation in abdomen, 730 
Fontanelles, 87 
Foot-and-mouth disease, 273 
Freckles in rheumatoid arthritis, 126 
Fremitus, friction, 491 

hydatid, 883 

peritonea], 754 

vocal, 490 
Friction fremitus, 491 

in pericarditis, 643 

sound, 511 

distinguished from pleural fric- 
tion, 642 
from rales, 510 
from vascular murmur, 642 
mediastinal, 650 
in pericarditis, 629, 641 
pleural, 511 
Friedreich's ataxia, 1044 

respiratory change of sound, 515 
Funnel- breast, 483 



G 



AIT in disease, 70 
Gall-bladder, aspiration of, 868 



Gall-bladder, cancer of, 889 

enlargement of, 887 

palpation of, 868 

tumors of, 888 

diagnosis of, 889 

distinguished from movable kid- 
ney, 909 
Gallstones, 885 

accidents resulting from, 887 

colic due to, 817 

obstruction of common duct by, 886 
Gangrene, 409 

of lung, 563 

hemoptysis in, 467 

from trophic disturbance, 1007 
Gastralgia, 770,771, 779 

neurasthenic, 800 
Gastrectasis, 807 
Gastric crises, 769 
acute, 791 
pain in, 771 

chronic, 805 

distinguished from ulcer and can- 
cer, 811 

mycotic and diphtheritic, 796 

phlegmonous, 796 

toxic, 796 
Gastrodiaphany, 774 
Gastrodynia, 770 
Gastroxynsis, 802 
Gerhardt's change of sound, 515 
Girdle pain, 55 
Glanders, 335 

bacillus of, 336 

diagnosis of, 336 

mallein test for, 336 
Glands, lymphatic, enlargement of, 159 
Glandular fever, 265 
Glenard's disease, 748 
Globulin in urine, 937 
Globus hystericus, 769, 1061 
Glossitis, 696 

dissecting, 698 
Glycosuria, 933,^ 935 

in pancreatic disease, 894 
Goitre, exophthalmic, 88 
Gonococcus, 363 

in blood, 308 
Gonorrhceal septicaemia, 307 
Gout, 183 

acute articular, 184 

blood in, 184 

chronic, 184 

gastric symptoms in, 762 

hand in, 114 

relation to lithsemia, 856 

retrocedent, 184 

teeth in, 691 
Gram's stain, 241 
Gums in cachexia, 690 

in lead-poisoning, 691 

in scurvy, 189, 691 



HABIT spasm, 1040 
Habits in etiology of disease, 25 



1070 



INDEX. 



Haematemesis, 792 

distinguished from haemoptysis, 793 
in gastric ulcer, 812 

cancer, 810 
in hepatic cirrhosis, 676 
Hematocele, pelvic, 744 
Haematoidin crystals, 364 

in pus, 527 
Haematokrit, 378 
Haematoporphyrinuria, 936 
Hematuria, 928, 940 
malarial, 288 
from overexertion, 904 
in renal calculus, 904 
cancer, 911 
Haemocytometer, 376 
Haemoglobin, 384 
Hsemoglobinometers, 384 
Haemaglobinuria, 929 
Hsemopericardium, 648 
Haemophilia, 129 

diagnosis of, 130 
Haemoptysis, 468, 521. See also Hemor- 
rhage, pulmonary. 
Hemothorax, 593 
Hair in diagnosis, 85 
Hallucinations, 1011 
Hands in acromegaly, 170 
deformities of, 110, 113 
swelling of, 113 
Hanging-drop, method of making, 241 
Harrison's groove, 172 
Hay-fever, 420, 547 
Head in rickets, 173 
Headache, anaemic, 42 

character of pain in, 52 
chronic, causes of, 52 
in indigestion, 770 
in infectious fevers, 201 
in inflammation of frontal bones, 49 
lithaemic, 770, 856 
ocular, 51 
in syphilis, 52 
in uraemia, 956 
Hearing impaired by drugs, 108 

tests for, 107 
Heart, aneurism of, 656 

area of absolute dulness, 614 
change in, 615 
graphic record of, 619 
in pericardial effusion, 
646 
of deep dulness, 616 
arrhythmia of, 587 
auscultation of, 619 
dilatation of, 670 
acute, 671 

area of dulness in, 616 
valve, shock in, 603 
disease of, etiological factors in, 582 
bradycardia in, 609 
cough in, 588 
dropsy in, 588 
dyspeptic symptoms in, 589 
dyspnoea in, 588 
general pathology of, 580 



Heart, disease of, haemoptysis in, 467, 588 
inspection in, 592 
kidneys in, 589 
nervous symptoms in, 588 
pain in, 583, 585 
praecordia in, 592 
retraction of interspaces in, 595 
in emphysema, 565 
fatty overgrowth of, 656 
hypertrophy of, 667 

area of dulness in, 616 
diagnosis of, 670 
impulse in, 593, 602 

epigastric, 597 
physical signs of, 668 
in valvular disease, 657 
impulse of, 592 

absence of, 594 

additional, 595 

area of, 595 

changes in position of, in health, 

593 
in dilatation, 671 
displacement of, 593 
palpation of, 601 
strength of, 602 
inflammation of muscles of. See Myo- 
carditis, 
irregular, in pericardial effusion, 645 
irritable, 587 
murmurs. See Murmurs, 
neuroses of, 581 
palpitation of, 586 
percussion of, 614 
pleximetric, 617 
repercussion of, 618 
physiology of, 591 
in pleural effusion, 571 
right side of, hypertrophy of, 669, 670 
rupture of, 656 

sounds, aortic accentuated, 625 
diminished, 626 
mitral, diminished, 626 
normal, 620 

diastolic, 623 
differentiation of, 623 
systolic, 621 
transmission of, 623 
pulmonary, accentuated, 625 

diminished, 626 
reduplication of, 627 

false, 629 
systolic, accentuation of, 624 
topography of, 590 
valves of, position of, 591 
valvular disease of, chronic, 656 

effects on heart and pulse, 639 
gastric symptoms in, 761 
weakness of, sphygmogram in, 612 
Heat exhaustion, 212 
Heberden's nodes, 114 
Hemianopsia, 102 
Hemiplegia, 977 
Hemorrhage, 405 

in central nervous disease, 131 
cerebral, 1053 



INDEX. 



1071 



Hemorrhage, gastric, 792 

distinguished from pulmonary 
hemorrhage, 469 
gastro-intestinal, in portal congestion, 

858 
internal, symptoms of, 406 
intestinal, 824 

in duodenal ulcer, 841 
from mucous membrane of mouth, 687 
from oesophagus, 719 
from pharynx, 709 
pulmonary, 466 

in capillary bronchitis, 546 

character of blood in, 468 

in chronic interstitial pneumonia, 

551 
distinguished from other forms, 

469,793 
in heart disease, 588 
in infarction of lung, 542 
in phthisis, 553, 560 
symptoms of, 468 
in scurvy, 189 
in thoracic aneurism, 677 
into skin, 126 

in anaemia, 127 
in fever, 127 
in jaundice, 862 
in septicaemia, 227 
toxic, 131 
in uraemia, 959 
Hemorrhoids, 853 
Hepatic colic, 885 

fever, 864 
Hepato-pulmonary abscess from dysentery, 

346 < 
Heredity, transmission of nervous diseases 
by, 961 
pulmonary diseases by, 455 
Hernia as a cause of intestinal obstruction, 

859 
Herpes labialis, 138 
zoster, 187, 1006 
Hiccough in gastric diseases, 773 
Hippocratic fascies, 81 
Hippus, 97 

Hodgkin's disease, 160, 399 
Hutchinson's teeth, 270, 691 
Hydatid cyst of liver, 883 

of lung, 568 
Hydrocephalus, 1056 

physiognomy of, 86 
Hydronephrosis, 911 

distinguished from hydatid cyst of 
liver, 884 
Hydropericardium, 648 
Hydrophobia, 273 
Hydrothorax, 573 
Hypaesthesia, 971 
Hypalgesia, 972 
Hyperacidity, gastric, 801 
Hyperaemia, active, 401 

passive or venous, 402 
Hyperaesthesia, 971 
of stomach, 798 
Hyperalgesia, 972 



Hyperorexia, 799 
Hyperpyrexia, 194 
Hyperthermoaesthesia, 973 
Hysteria, 1059 

detection of, 89 

joint in, 189 

pseudo-angina in, 586 
Hysterical mimicry of disease, 33 



[DIOCY, 1010 
L Impetigo, 255 

Impulse of heart, 592. See Heart, im- 
pulse of. 
Indicanuria, 935 

in empyema, 573 

in gastric cancer, 810 

in intestinal obstruction, 849 
Indigestion, gastric, 797 

intestinal, 836 
Infarction, 404 

of lung, 467 
Infections, classification of, 219 

etiology of, 218 

fever in, 203 

history in diagnosis of, 246 

pulse in, 608 

terminal, 228 
Inflammation, 407 

of mucous membrane, 408 

of serous membrane, 408 
Influenza, 323 

bacillus of, 536 

diagnosis of, 325 

ophthalmic neuralgia in, 48 
Inheritance in the etiology of disease, 27 
Inoculation of animals, 244 
Intermittent fever. See Malarial Fever, 

280. 
Intestines, amyloid degeneration of, 841 

cancer of, 852 

catarrh of, acute, 837 
chronic, 840 

disease of, physical signs in, 825 

obstruction of, acute, causes of, 843 
symptoms of, 846 
chronic, causes of, 844 
symptoms of, 846 
diagnosis of, 847, 850 

parasites in, 814 

tuberculosis of, 842 

ulceration of, 841 
Intoxication, alcoholic, 214 

fever in, 209 

by food, 213 

by grain, 214 

by lead, 215 
Intussusception, 744, 844, 849 
Iritis, 97 



JAUNDICE, 121 
O acute febrile, 271 
bradycardia in, 609 
catarrhal, 862, 866 
in cholelithiasis, 88( 



1072 



INDEX. 



Jaundice, in congestion of liver, 859 

fever in, 864 

hematogenous, 863 

hepatogenous, 862 

infantile, 865 

malignant, 864 

symptoms of, 861 
Joints, crepitus in, 177 

enlargement of, 176 

fluctuation in, 177 

hysterical, 189 

movability of, 177 

pain in, 176 

pathological processes in, 177 

position assumed, 177 

in rheumatic fever, 179 

in tabes dorsalis, 189 

trophic lesions of, 1008 

tuberculosis of, 178 



KERNIG'S sign of cerebro -spinal fever, 
330, 1053 
Kidney, abscess of, 913 
congestion of, 960 
cystic, 911, 967 
degeneration of, 967 
enlargement of, 910 

distinguished from enlarged spleen, 
892 
granular, 964 
in heart disease, 589 
horseshoe, 909 
hydatid cyst of, 914 
inflammations of. See Nephritis, 
movable, 907 

distinguished from tumor of gall- 
m bladder, 889 
pain in disease of, 901 
palpation of, 906 
percussion of, 907 
sarcoma and carcinoma of, 910 
topography of, 906 
Knee-jerk, 986 
Koch's postulates, 218 
Koplik's sign of measles, 261 



] AGOPHTHALMOS, 92, 1026, 1054 
-Li Landry's paralysis. 1050 
Laryngismus stridulus, 434 

in rickets, 174 
Laryngitis, acute, 441 

with stenosis, 442 

chronic, 432 

membranous and diphtheritic, 443 

spasmodic, 443 

submucous, 445 
Laryngoscopy, 437 
Larynx, color of mucous membrane in, 439 

cough in disease of, 435 

dysphagia in disease of, 435 

dyspnoea in disease of, 433 

foreign bodies in, distinguished from 
whooping-cough, 445 

hemorrhage from, 436 



Larynx, inco-ordination of muscles of, 436 
lupus of, 440 
oedema of, 443 

distinguished from membranous 
laryngitis, 444 
pain in, 431 

paraesthesia, hyperaesthesia, and anaes- 
thesia of, 432 
paralysis of muscles of, 445 
perichondritis of, 431 
syphilis of, 439, 440, 448 
tuberculosis of, 439, 440, 447 

distinguished from syphilis, 448 
tumors of, 440, 447 
Lathy rism, 215 
Lead- poisoning, 215 

colic in, 817 
Leprosy, 349 

in mouth, 694 
organism of, 349 
Leptomeningitis, 1052 
Leptothrix buccalis, 690 

in sputum, 529 
Leucin in urine, 953 
Leucocythaemia, 396 
acute, 399 
blood in, 397 
lymphatic form of, 399 
spleen in, 892 

splenomedullary form of, 396 
Leucocytosis, 381 

absence of, in typhoid fever, 299 
in infectious disease, 238 
in pneumonia, 315 
Leucopenia, 382 

Leukaemia. See Leucocythaemia, 396 
Linea albican tes, 728 
Lipaemia, 386 
Lipomata, peritoneal, 733 
Lips in diagnosis, 85 
Lipuria, 947 
Lithaemia, 855 

neuralgia in, 48 
Liver, abscess of, 346, 872 
diagnosis of, 874 
distinguished from cancer, 882 
acute yellow atrophy of, 864 
amyloid disease of, 866, 880 
arterial pulsation of, 604 
auscultation of, 868 
cancer of, 880 

palpation in, 867 
cirrhosis of, atrophic, 876 

collateral circulation in, 877 
gastric symptoms in, 762 
hypertrophic, 878 

distinguished from cancer, 
882 
syphilitic, 879 
congestion of, 857 
constriction of, from lacing, 867 
diminution in size of, 869 
enlargement of, 869 

conditions with which confounded, 
870 
etiological factors in disease of, 859 



INDEX. 



1073 



Liver, fatty, 866, 880 

floating, 867 

functional disturbances of, 855 

hydatid disease of, 883 
tumor in, 867 

pain in, 873 

palpation of, 866 

syphilis of, 879 

topographical anatomy of, 860 
Localization of lesions of nervous system, 

1011 
Locomotor ataxia. See Tabes dorsalis, 

1043 
Logorrhcea, 1006 
Lud wig's angina, 717 
Lumbago, 167 
Lumbar puncture, 359 

in cerebro spinal fever, 328 
Lung or lungs, abscess of, 563 

boundaries of, in disease, 498 

collapse of, 548 

congestion of, 540 

cough in diseases of, 464 

diminution of air space in, 458 

embolism and thrombosis of, 541 

gangrene of, 521, 563 

general svmptomatologv of disease of, 
452 

history in disease of, 455 

hydatid disease of, 568 

neuroses of, 540 

oedema of, 540 

percussion sounds in disease of, 498 

relationship of. to heart, 453 

size of, in phthisis, 561 

topographical anatomy of, 473 

tuberculosis of, 552. See Tuberculosis, 
pulmonary. 

tumors of, 567 
Lupus of larynx, 440 
Lymphadenoma, 399 
Lymphangitis, 161 

in septicaemia, 227 
Lymphatic glands in leucocythaemia, 399 
Lymphatism, 162 
Lymphocytosis, 382 
Lymphosarcoma, 158, 160 



MACROGLOSSIA, 700 
Main en griffe, 1009 

Malarial cachexia. 239 

neuralgia in, 48 
spleen in, 892 
fever, 279 

diagnosis of, 283 
intermittent, 285 
irregular forms of, 285 
pernicious, 287 
Plasmodia of, 282 
remittent, 287 

Mallein test for glanders, 336 

Malta fever, 305 

Mania, 1010 

McBurney's point, 739 

Measles, 260 



Measles, distinguished from scarlet fever, 

259 
Meat-poisoning, 213 
Mediastinal friction, 650 

tumors, 684 
Mediastinitis, 683 

Mediastino-pericarditis, ^indurative, 650 
j Medicinal rashes, 139 
I Melaena, 825 
| Melanaemia, 386 
Melancholia, 1011 
Melanuria, 954 
Meniere's disease, 108, 1059 

station in, 74 
Meningitis, 1052 

chronic internal spinal, 1048 
epidemic cerebro-spinal, 326, 1047 
complications and sequelae of, 328 
distinguished from typhoid fever, 

302 
Kernig's sign of, 330 
lumbar puncture in, 328 
organism of, 329 
symptoms of, 327 
temperature in, 326 
from pneumococcus infection, 318 
syphilitic, 1047 
Mensuration of chest, 515, 517 
Mental disturbances, 1010 
Meralgia paraesthetica, 1043 
Merycismus, 803 
Metallic tinkling in chest, 512 
in pneumothorax, 578 
Metatarsalgia, 54 

Micrococci, general characteristics of, 220 
Micrococcus lanceolatus, 363, 534 
Micturition, frequent, 906 
Migraine, 49, 1059 
vTiliaria, 140 
Miliary fever, 272 
Milk-poisoning, 214 

sickness, 273 
Mitral area, 632 

insufficiency, 660 

broken compensation in, 661 
physical signs of, 662 
stenosis, 663 

physical signs of, 664 
pulmonary second sound in, 626 
thrill in, 603 
Monoplegia, 979 
Morphinism, 212 
Morphcea, 157 

Morton's painful affection of foot, 54 
Mor van's disease, 1051 
Motor points of muscles, 994 
Mountain fever, identity with typhoid, 303 
Mouth-breathing, 417, 426 

color of mucous membrane of, 687 
dryness of, 686 

hemorrhage into mucous membrane 
of, 687 
Mumps, 84, 265 
Murmurs of anaemia, 637 
in aortic aneurism, 680 
area, 633, 634 ^ 



1074 



INDEX. 



Murmurs in aortic obstruction, 659 
regurgitation, 658 
arterial, 640 
double, 641 
from pressure, 641 
cardio-muscular, 638 
-respiratory, 638 
character of, 635 
combined, 640, 667 
disappearance of, 637 
of Flint, 658 

influence of pressure on, 638 
loudness of, 636 
at mitral area, 633, 634 
of mitral insufficiency, 662 

stenosis, 664 
position of maximum intensity of, 631 
presystolic, 664, 665 
at pulmonary area, 634 
in relative incompetency, 637 
time of, 632 
transmission of, 635 
in tricuspid stenosis, 666 
at tricuspid area, 633, 634 
vascular, 629 
Muscular atrophy, 164, 989 
diagnosis of, 164 
peroneal type of, 164 
progressive, 1034 

consecutive to disease of 

nerves, 1037 
spinal, 1038 
table of, 165 
hypertrophy, 166 
ossification, 167 

paralysis, pseudo-hypertrophic, 1036 
tone, 983 
Muscles, extra-ocular, actions of, 92 
affections of, 93 
disturbed balance of, 95 
functional classification of, 1027 
lack of tone in, 78 
Myalgia, 167 

distinguished from neuralgia, 45 
occipital and frontal, 47 
Mydriasis, 98 
Myelitis, acute, 1049 
chronic, 1049 
disseminated, 1049 
Myelocytes, 383 
Myocarditis, 654 
Myoidema, 163 
Myosis, 98 
Myositis, 166 
Myotonia congenita, 166 
Myotonic reaction, 999 
Myxoedema, 154 



NAILS in diagnosis, 116 
disturbed nutrition of, 1007 
Nasal discharge, a portent of uraemia, 418 
Nasopharynx, adenoid vegetations in, 714 
Nausea in gastric disease, 764 
in headache, 52 
ursemic, 957 



I Necrosis of tissue, 409 
I Nephritis, acute exudative or glomerulo, 
961 
with pus formation, 962 
productive, 962 

chronic productive, 962 

without exudation, 964 

erythema in, 140 

gastric symptoms in, 762 

interstitial, 964 

retinitis in, 100 

suppurative, 966 

tubercular, 967 
Nephrolithiasis, 902 

colic in, 817 
Nervousness, 34 
Neuralgia, 1041 

causes of, 53 

character of pain in, 47 

distinguished from myalgia, 45 

intercostal, distinguished from pleu- 
risy, 470, 576 / 

from local irritation, 47 

malarial, 285 

points of tenderness in, 45 

reflex from eye, teeth, or tongue, 48 

secondary, 49 

symptoms of, 52 

from systemic conditions, 48 

trigeminal, 47 
Neurasthenia, 1061 
Neurasthenic gastralgia, 800 
Neuritis, 1047 

of optic nerve, 100 
Neuromata multiple, 1046 
Neurons, motor, lesions of, 1013 

sensory, lesions of, 1012 
Neuroses, gastric, 797 

of lungs and bronchi, 540 

of occupation, 1041 

reflex, 420 
Neusser's granules, 383 
Night-blindness, 189 

restlessness in adenoid disease, 716 

sweats of phthisis, 559 
Nigrities, 696 
Nodes on bone, 175 
Nose, 426 

appearance of mucous membrane of, 
423 

auxiliary cavities of, disease of, 429 

deformity of, 421 

examination of, 421 

obstruction of, 420 

polypi in, 424 

relation of disease of, to asthma, 420 

ulceration in, 424 
Nucleo-albumin in urine, 928 
Nyctalopia, 189 
Nystagmus, 95 



OBJECTIVE symptoms, methods of ob- 
serving, 60 
Obstipation, 822, 825 
Occipital neuralgia, 1042 



INDEX. 



1075 



Occupation in etiology of disease, 26 

neuroses of, 1041 
(Edema, angio- neurotic, 153 

of arms and thorax, 151 

diagnosis of, 150 

of feet, 151 

general, 153 

in heart disease, 588 

inflammatory, 150 

local, 150 

significance of, 152 

of lungs, 540 

mode of recognition of, 149 

in nephritis, 961 

pathology of, 148 

in trichinosis, 151, 354 

in uraemia, 959 
Oesophagitis, 721 
(Esophagus, abscess of, 721 

carcinoma of, 722 

dilatation of, 723 

examination of, 719 

foreign body. in, 722 

obstruction of, 720 

spasm of, 723 

stricture of, 721 
Oidium albicans, 690 

in sputum, 529 
Oligochromsemia, 585 
Oligocythemia, 379, 395 
Ophthalmoplegia, 105 
Ophthalmoscopy, 99 
Opisthotonos, 70 
Opium habit, 212 

Optic atrophy in tabes dorsalis, 101 
Osteitis deformans, 170 
Osteo-arthropathy, pulmonary, bones in, 

171 
Osteomalacia, 174 
Osteomyelitis, 175 
Ovarian cysts, 367 

diagnosis of, 745 
Oxaluria, 952 
Oxyuris vermicularis, 833 

symptoms of, 815 
Ozsena, 425 

in glanders, 335 



PACHYMENINGITIS, external cere- 
I bral, 1052 

hypertrophic cervical, 1047 
Pain in abdomen, 726 

in appendicitis, 739, 818 

in arms, 54 

character of onset of, 41 

in chest in phthisis, 360 

crises of, 44 

deep seated, 44 

definition of, 36 

in diarrhoea, 821 

duration of, 41 

in epigastrium, 584, 770 
in relapsing fever, 275 
in uraemia, 957 

estimation of, 38 



Pain, etiology of, 37 

in extra-uterine pregnancy, 817 

in foot in flat-foot, 54 

in gastric disease, 771, 775, 818 

ulcer, 812 
general, 43 

in rickets, 173 
girdle, 55 
in heel in gout, 54 
indicating location of disease, 43 

nature of disease, 42 
inframammary, 56 
intermittent or remittent, 41 
in intestinal obstruction, 818 
in joints, 176 
kinds of, 42 
in larynx, 431 
in legs, 53, 54 

in cerebral hemorrhage, 54 
in loins, 57 
measurement of, 40 
modes of expression of, 37 
in mouth, 686 
muscular in trichinosis, 354 
in nasal disease, 419 
in oesophagus, 718 
in otitis media, 49 
in pancreatic disease, 818 
paroxysmal, 42 
in pericarditis, 643 
periodic, 42 
peripheral of central origin, 36, 44, 

54 
in peritonitis, 750, 818 
in pharynx, 707 
in pleurisy, 469, 569, 575 
in prsecordia, 583 
in rectum, 817 
referred, 43, 44 
in scalp, 46 
sense, 973 
in shock, 40 

simulated, 39. See also Feigned dis- 
ease. 
in spine, 55, 56 

in and behind sternum, 55, 175 
superficial, 43 
sympathetic, 43 
in thoracic aneurism, 676 
in vertebral disease, 819 
visceral, 973 
Palpitation of heart, 586 
in gastric disease, 773 
in lithsemia, 856 
Palsies, local and multiple, 978 
Pancreas, cancer of, 894 

distinguished from hepatic can- 
cer, 882 
cysts of, 898 

distinguished from enlarged liver, 
871 

fluid in, 367 
diseases of, 893 
hemorrhage into, 895 
tumors of, 746, 894 
Pancreatitis, acute hemorrhagic, 895 



1076 



INDEX. 



Pancreatitis, acute hemorrhagic, distin- 
guished from acute intestinal ob- 
struction, 851 

gangrenous, 897 

suppurative, 897 
Papillitis, 100 
Papilloma of larynx, 440 
Paradoxical contraction of Westphal, 989 
Paresthesia, 970 
Paralysis, 976 

agitans, 1040 

bulbar, 1054, 1056 

crossed, 1014 

diphtheritic, 333 

Landry's, 1050 

local, in uraemia, 957 

myopathic, 978 

of orbital nerves, 106 

periodic, 1039 

pseudo-hypertrophic muscular, 1036 
gait in, 72 
station in, 74 
Paramyoclonus multiplex, 166, 1040 
Paranoia, 1011 
Paraphasia, 1001 
Paraplegia, 978 

hysterical, gait in, 72 

primary spastic, 1046 
gait in, 71, 72 

from Pott's disease, 1048 
Parasites, anaemia due to, 391 

in intestines, 814 

in mouth, 693 

in sputum, 528 
Paresis, 979 

general, of the insane, 1057 
Parosmia, 419 
Parotitis, epidemic, 84 

symptomatic, 718 
Pectoriloquy, 413 
Peliosis rheumatica, 129 
Pellagra, 215 
Percussion, 492 

auscultatory, 497 

of chest, amphoric sound in, 501 
cracked-pot sound in, 501 
dulness in, 500 
hyper-resonance, 498 
impaired resonance, 499 
normal sounds in, 494 
tympany in, 499 

respiratory, 497 

superficial and deep, 497 
Pericardial friction sound, 603, 629 

distinguished from pleural, 630 
Pericarditis, 641 

acute fibrinous, 641 

adhesive, 648 

with effusion, 644 
impulse in, 593 

pain in, 584 

physical signs of, 645 

from pneumococcus infection, 318 
Pericardium, aspiration of, 358 
Perinephritic abscess, 913 
Periostitis, 175 



Peristalsis, visible, 729, 774 
Peritonitis, 750 

chronic, 754 

diagnosis of, 752 

in dysentery, 347 

hysterical, 753 

localized, 753 

tuberculous, 755 
Perspiration in crisis of pneumonia, 145 

diminished, 146 

increased, 145 

local, 146 

in miliary fever, 272 

in phthisis, 559 

in rheumatic fever, 145, 180 

in rickets, 173 

in tuberculosis, 145 
Pertussis, 265 

bacillus of, 536 

cough in, 466 
Petit mal, 1058 
Phantom tumor, 734, 1061 
Pharyngitis, acute, 716 

chronic, 717 

lithsemic, 856 

phlegmonous, 717 

rheumatic, 717 
Pharynx, adenoids of, 714 

anaesthesia of, 710 

color of mucous membrane of, 709 

examination of, 708 

pseudomembrane on, 710 

spasm of, 708 

ulcers in, 709 
Phlebitis in septicaemia, 227 
Phlegmasia alba dolens, 403 
Phosphates in urine, 950 
Phosphorus-poisoning, 865 
Photophobia, 92 
Phrenic nerve, paralysis of, 461 
Phthisis. See Tuberculosis, pulmonary, 

555. 
Physical signs, pictoric record of, 536 
Pica, 772 

Pigeon-breast, 715 
Pigmentation of skin, 124 
Plague, bubonic, 347 

bacillus of, 348 
Plasmodia of malaria, 282 

staining of, 284 
Plate cultures, 243 
Plethora, 401 
Pleural friction sound, distinguished from 

pericardia], 630 
Pleurisy acute, 569 

distinguished from intercostal neu- 
ralgia, 470, 576 
from pleurodynia, 469, 576 
from pneumonia, 575 
physical signs of, 570 

chronic, 576 

with thickening, 576 

cough in, 465 

diaphragmatic, 574 

etiology of, 569 

with effusion, 570 



INDEX. 



1077 



Pleurisy, with effusion, aegophony in, 513 
aspiration of, 358 
character of fluid in, 365 
distinguished from consolidation, 
575 
from enlarged liver, 870 
from hydatid cyst of liver, 
^884 
heart in, 571 

shape and size of chest in, 484 
movements of chest in, 487, 488 
pain in, 469 

from pneumococcus infection, 318 
tuberculous, 574 
Pleurodynia, 167 

distinguished from pleurisy, 469, 488, 
576 
Plumbism, 215 
Pneumatosis, 802 
Pneumococcus, 363 

septicaemia due to, 318 
Pneumokoniosis, 550 
Pneumonia-broncho-, 549 

distinguished from collapse of 

lung, 549 
physical signs of, 549 
tuberculous, 550 
bronchophony in, 513 
chronic interstitial, 550 
crepitant rales in, 510 
croupous or lobar, 311 

bacteriological diagnosis of, 318 
central variety, 311 
cerebral symptoms in, 314 
chlorides in urine in, 315 
critical sweats in, 145 
diagnosis of, 317 
distinguished from collapse of 

lung, 548 
in drunkards, 317 
duration and course of, 316 
heart and pulse in, 314 
massive, 315 
organism of, 534 
physical signs of, 315 
respiration in, 312 
sputum in, 312 
varieties of, 316 
in infants, 317 
movements of chest in, 487 
pulmonary second sound in, 625 
sputum of, 521 
Pneumopericardium, 648 
Pneumoperitoneum, 751 
Pneumothorax, 577 
diagnosis of, 578 

distinguished from emphysema, 566 
Poikilocytosis, 375 
Poisoning. See Intoxication, 209 
Poliomyelitis, anterior, 1038 
Polyphagia, 803 
Polypi, nasal, 424 
Pons, lesions of, 1019 
Portal vein, obstruction of, 858 

pyaemia, 858 
Pott's disease, paraplegia in, 1048 



Praecordia, prominence of, 592 

Previous disease, bearing of, on diagnosis, 

29 
Pregnancy, pigmentation in, 125 

vomiting in, 767 
Pressure, sense of, 975 
Proctitis, 839 
Pruritus, 134 

in jaundice, 861 

in uraemia, 957 
Ptosis, 91 
Ptyalism, 694 
Pulmonary disease. See Lung. 

valve disease, 666 

area, 632 
Pulsation of arteries, 587, 596 

a subjective symptom, 590 

epigastric, 596, 728 

of veins, 599 
Pulse in aortic aneurism, 681 

capillary, 598, 659 

Corrigan's, 658 

in fever, 199 

frequency of, 604, 608 

high tension, sphygmogram in, 613 

irregular, sphygmogram in, 614 

low tension, sphygmogram in, 613 

method of taking, 604 

in peritonitis, 752 

in rheumatoid arthritis, 186 

rhythm of, 607 

tension of, 606 
in fever 

venous, 600 

volume of, 606 
Pulsus paradoxus in adherent pericarditis, 
649 
in pericardial effusion, 645 
Puncture, exploratory, 357 
Pupillary reflex, 97 
Purpura, 128 
Pus, bacteria of, 240, 360 

chemical examination of, 364 

physical characteristics of, 360 

staining of, 240 

tubercular, 362 

in urine, 936, 941 
Pyaemia, 224 
Pyelitis, 912 

Pylephlebitis, suppurative, 875 
Pylorus, stenosis of, 808 
Pyonephrosis, 912 
Pyopneumothorax, 577 

subphrenicus, 578, 747 
Pyorrhoea alveolaris, 691 
Pyrosis, 772, 802 
Pyuria, 936 

absence of in renal calculus, 905 



RHACHITIS. See Eickets, 172 
Rales, 509 

distinguished from friction sound, 
510 
Ranula, 697, 700 
Eashes, medicinal, 139 



1078 



INDEX. 



Kay fungus, 351 
Raynaud's disease, 115, 1006 
Eeactions of degeneration, 996 

atypical, 999 
Records of cases, 21 
Rectum, diseases of, 852 
Reflex, abdominal, 986 
patellar, 987 
plantar, 989 
reinforcement of, 987 
tendo-Achillis, 988 
tendon, 985 
Regions of chest, 471 
Regurgitation of food, 772 

in disease of oesophagus, 723 
Reichman's disease, 801 
Relapsing fever, 274 

serum diagnosis in, 276 
spirillum of, 275 
Renal calculus, 902 

colic, 902 
Residence in etiology of disease, 26 
Resistance to finger in percussion, 496 
Resonance, pulmonary, 494 
Respiration, Cheyne-Stokes, 487 
in fever, 199 
rate of, 476, 486 

ratio of inspiration to expiration, 486 
types of, 476 
Restlessness, 70 
Retinitis, 100 

albuminuric, 959, 965 
Retraction of interspaces in adherent peri- 
cardium, 649 
Retroperitoneal sarcoma, 754 
Retropharyngeal abscess, 717 
Rhabdenoma intestinale, 834 
Rheumatic fever, 178 

complications and sequelae of, 181 
diagnosis of, 181 
endo- and pericarditis in, 180 
temperature in, 180 
Rheumatism, acute articular. See Rheu- 
matic fever, 
chronic articular, 183 
gastric symptoms of, 762 
gonorrhoeal, 178 
hand in, 113, 114 
muscular, 167 

relation of, to lithsemia, 856 
subacute articular, 182 
subcutaneous nodules in, 158 
Rheumatoid arthritis, 185 
diagnosis of, 187 
fingers in, 114 
pulse in, 186, 608 
Rhinitis, atrophic, 425 
caseous, 425 

chronic hypertrophic, 424, 428 
idiopathic, 420 
sicca, 429 
simple acute, 427 
syphilitic, 429 
Rhinoscopy, 421 
Rickets, 172 

diagnosis of, 174 



Rickets, fontanelles in, 87 

shape of chest in, 480 

sweating of head in, 146 
Rigidity of abdomen in peritonitis, 751 
Roseola, 139 
Rotheln, 264 
Rubella, 264 

distinguished from scarlet fever, 259 
Rumination, 803 



O ALIVA, 687 
O in disease, 689 
Salivation, 687 
Saltatoric spasm, 1040 
Sarcina, 220 

in gastric contents, 784 

in urine, 948 
Sarcoma, retroperitoneal, 754 

of skin, 157 
Scalp, pain in, 46 
Scanning speech, 1006 
Scaphoid abdomen, 735 
Scarlet fever, 255 

complications and sequela? of, 258 
diagnosis of, 258 
pulse in, 608 
tongue in, 701 
varieties of, 257 
Scars, significance of, in diagnosis, 146 
Sciatica, 53, 1043 
Scleroderma, 157 
Sclerosis, amyotrophic lateral, 1046 

multiple or insular, 1047 
gait in, 71 
Scotoma, 102 
Scurvy, 188 

gums in, 691 

hemorrhage in, 128 

-rickets, 189 
Seitz's sign of cavity, 515 
Sensation, 971 

delayed, 975 

dissociation of, 973 

of locality, 974 

muscular, 975 

of pain from induced current, 975 

of pressure, 975 

stereognostic, 976 

tactile, 971 

of temperature, 973 
Septicemia, 225 

fever in, 210 
Septico-pysemia, 334 
Serum diagnosis, 233 

dilution and time limit in, 236 

the appearance of the reaction, 236 

in relapsing fever, 276 

in typhoid fever, 235, 299 

value of, 237 

with dried blood, 236 

with fluid serum or blood, 234 
Sex in etiology of disease, 25 
Shell-fish poisoning, 214 
Shock, 65 

effect of, on pain, 39, 40 



INDEX. 



1079 



Shock from hemorrhage, 406 
Shortness of breath, 462. See Dyspnoea. 
Siderosis, 551 
Skin, color of, 119 

hemorrhage into, 126 
lesions of, artificial, 41 
classification of, 132 
general diagnosis of, 141 
syphilitic, 142 
traumatic, 141 
ulcerative, 144 
malignant nodules under, 157 
nutrition of, 144 
pigmentation of, 125 
Skodaic resonance, 499 

in pleural effusion, 570 
in pneumonia, 315 
Smallpox. See Variola, 250 
Smell, disturbance of sense of, 419 
Spasm, habit, 1040 
muscular, 981 
saltatoric, 1040 
Speech, disturbances of, 1000 
Spermatozoa in urine, 946 
Sphygmograph, 609 

Spinal cord, general symptoms of disease 
of, 1024 
hemorrhage into, 1050 
pressure on, symptoms of, 1050 
traumatism of, 1051 
tumor of membranes of. 1 048 
localization, 1021 
Spirilla, general characteristics of, 222 
Spirillum of cholera Asiatica, 338 
nostras, 835 
of relapsing fever, 275 
Spirometry, 516 
Spleen, amyloid, 893 
diseases of, 890 
enlargement of, 891 

in cirrhosis of liver, 877 
in Hodgkin's disease, 161 
in infants, 893 
in leucocythsemia, 396 
in malaria, 289 
in pneumonia, 314 
in simple anaemia, 392 
floating, 890 
hydatid cyst of, 893 
malignant tumors of, 893 
palpation of, 890 
percussion of, 890 
puncture of, 360 
syphilis of, 893 
topography of, 890 
Splenitis, acute, 891 
Spores of bacilli, 221 
Sputum, 519 

in bronchiectasis, 566 

in bronchitis, capillary, 546 

plastic, 546 
chemistry of, 536 
in gangrene of lung, 563 
from larynx, 441 
in liver abscess, 529 
in lobar pneumonia, 312 



Sputum, method of collecting, 519 
micrococcus lanceolatus in, 534 
microscopic examination of, 522 
in phthisis, 561 
physical characteristics of, 520 
tubercle bacilli in, 530 
Staining of bacteria, 240 
Staphylococci, 361, 362 
Station in disease, 74 
Stelwag's sign, 89 
Sterilization in bacteriology, 231 
Stethoscope, 502 
Stiff neck in oesophagitis, 719 
Stigmata of the passion, 1061 
Stokes- A dams' syndrome in myocarditis, 

589, 655 
Stomach, absorptive power of, 790 
anaesthesia of, 803 
atony of, 803 
auscultation of, 778 
auscultatory percussion of, 777 
carcinoma of, 808 

distinguished from ulcer and 

chronic gastritis, 811 
gastric contents in, 810 
cirrhosis of, 806 
catarrh of. See Gastritis, 
contents, acetic acid in, 788 
alcohol in, test for, 788 
anacidity of, 791 
bile in, 782 
blood in, 782 
butyric acid in, 788 
carbohydrates in, 789 
chemical examination of, 784 
clinical value of examination of, 

791 
free acid in, test for, 784 
hydrochloric acid in , test for, 785 
hyperacidity of, 791 
lactic acid in, significance of, 792 

test for, 787 
method of securing, 779 
microscopical examination of, 783 
mucus in, 782 
pepsinogen in, 789 
rennin in, 789 
syntonin in, 789 
total acidity of, 784 
cough, 465 

digestive power of, 789 
dilatation of, 777, 807 
diminution in size of, 777 
general condition in disease of, 793 
history in disease of, 763 
hyperacidity and hyperemia of, 801 
inspection of, 774 
internal exploration of, 775 
motor power of, 790 
neuroses of, 797 
nervous mechanism of, 760 
in other diseases, 761 
palpation of, 775 
percussion of, 776 
position of, 776 
relaxation of orifices of, 803 



1080 



INDEX. 



Stomach, tumor of, 775 

ulcer of, 811 
Stomatitis, 692 

aphthous, 693 

catarrhal, 693 

gangrenous, 694 

materna, 693 

mercurial, 694 

parasitic, 693 

ulcerative, 693 
Stools in amoebic dysentery, 343 

in catarrhal dysentery, 345 

in cholera, 337 

in diarrhoea, 820 
Streptococcus pyogenes, 362 
Strongylus, symptoms of, 815 
Stuttering and stammering, 1006 
Subdiaphragmatic abscess, 746 
Sublingual ulcer, 695 
Succussion, Hippocratic, 512 

in pneumothorax 577 

splash in stomach, 778 
Sudamina, 140 
Sugar in urine, 931 

Sulphocyanide of potassium in saliva, 689 
Sunstroke, 211 

fever in, 203 
Suppuration, symptoms of, 408 
Suprarenal capsules, disease of, 734 
Sweat. See Perspiration. 
Symptoms, evolution of, 31 

objective, definition of, 17 

subjective, definition of, 17 
valuation of, 32 
Syncope, 64 
Synovitis, 178 
Syphilis, acquired, 269 

caries of frontal bone in, 87 

coryza in, 429 

effect of mercury on haemoglobin in, 
271 

fever in, 206, 229 

headache in, 49, 592 

hereditary, 270 

of larynx, 439, 448 

of liver, 879 

lymphatic glands in, 159 

nasal ulceration in, 424 

neuralgia in, 48 

of pharynx, 709 

skin lesions in, 142 

teeth in, 691 
Syringomyelia, 1050 



TABES dorsalis, 1043 
cervical type of, 1044 
gait in, 70 
joints in, 189 
pain in, 55 
pulse in, 608 
mesenterica, 748 
Tache cerebral, 1052 
Tachycardia, 608 

in exophthalmic goitre, 89 
Taenia, 831 



Taenia, symptoms of, 814 
Teeth, 691 

Hutchinson's, 27] 

in rickets, 172 

time of eruption of, 692 
Teething, 692 
Temperature. See also Fever. 

danger limit of, 194 

determination of, 192 

influence of age and sex on, 208 

normal variation in, 194 

pathological variations in, 194 

sense of, 973 

subnormal, 201 

when to take, 193 
Tendon reflexes, 985 
Tenesmus, 42 

in diarrhoea, 821 
Tension in arteries, 606 
Tetanus, 352 

bacillus of, 353 
Tetany, 1040 

in dilatation of stomach, 807 

in rickets, 174 
Thermoanesthesia, 973 
Thirst in gastric disease, 764 
Thomsen's disease, 166, 1041 
Thorax. See Chest. 
Thrill in aortic aneurism, 679 
obstruction, 659 

cardiac, 603 

in mitral stenosis, 664 

in tricuspid stenosis, 666 
Throat in scarlet fever, 256 
Thrombosis^ 403 

in arterio-capillary fibrosis, 673 

cerebral, 1054 
Thrush, 690 

Thumb-sucking, effect on dental arch, 687 
Thyroid gland, enlargement of, 88 
Tic douloureux, 47, 53, 1042 

facial, 982 

general, 1040 
Tinea, 143 
Tinnitus aurium, 107 
Tongue, 695 

atrophy of, 700 

coating of, 700 

cysts of, 700 

diagnostic significance of, 704 

discoloration of, 695 

dryness of, 704 

furrows in, 697 

geographical, 700 

hypertrophy of, 700 

movements of, in disease, 706 

in prognosis and treatment, 705 

of scarlet fever, 257 

ulcers of, 698 

white patches on, 699 
Tonsillitis, acute, 711 

chronic, 714 

distinguished from diphtheria, 713 

follicular, 712 

suppurative, 712 
Tonsils, the, 710 



INDEX. 



1081 



Tonsils, foreign body in, 714 
leptothrix in, 711 
pseudomembraue on, 711 
ulcers of, 711 
Tooth-cough, 465 
Tophi in gout, 184 
Tormina ventriculi, 803 
Torticollis, 168 _ 
Toxaemia, fever in, 203 
Toxins and toxalbumins, 221 
Trachea, obstruction of, 457 
Tracheal tugging in aneurism, 88, 681 
Transudations, 365 
Traube's semilunar space, 776 
Tremor, 980 

in exophthalmic goitre, 90 
Trichina spiralis, 354, 834 
Trichinosis, 354 

eosinophilia in, 356 
face in, 84 
oedema in, 151 
Trichoaesthesia, 973 

Trichomonas in genito-urinary tract, 949 
Trichterbrust, 483, 715 
Tricocephalus dispar, 834 
Tricuspid area, 632 
regurgitation, 665 

venous pulse in, 600 
stenosis, 666 
Trismus neonatorum, 353 
Trophic disturbances, 1006 
Trousseau's sign of tetany, 1041 
Tubercle bacillus, 530 
Tuberculin test, 321 

in tubercular adenitis, 161 
Tuberculosis, 319 

acute miliary, 322 

distinguished from typhoid fever, 

302, 555 
pulmonary type of, 554 
bacillus of, 530 
cervical glands in, 1 59 
fever in, 205 

hereditary tendency to, 320 
of intestine, 842 
of kidney, 967 
of pharynx, 709 
pulmonary, acute, 552 

distinguished from pneumo- 
nia, 554 
chronic, 555 

diagnosis of, 319 

excursion of diaphragm in, 

477 
fever in, 558 
gastric symptoms in, 761 
haemoptysis in, 467, 560 
inspiratory capacity in, 518 
modes of invasion in, 556 
movements of chest in, 488 
pain in chest in, 560 
physical signs of, 561 
sputum in, 561 
sweats in, 559 
of tongue, 699 
Tuberculous peritonitis, 755 



Tuberculous peritonitis, acute, distin- 
guished from perforating ap 
pendicitis, 743 
diagnosis of, 758 
tumors in, 757 
Twitching, fibrillary muscular, 989 
Tympany, a percussion sound, 495 
Tympanites in peritonitis, 732, 751 
Typhlitis, 742 

stercoral, 824 
Typhoid fever, 289 

absence of leucocytosis in, 299 
bacillus of, 298, 300 
Baruch's sign of, 301 
complications and sequelae of, 298 
diagnosis of, 301 

distinguished from appendicitis, 
740 
from malignant endocarditis, 

652 
from typhus fever, 249 
eruption in, 296 
heart-sounds in, 294 
incubation of, 289 
nervous symptoms of, 294 
pulse in, 291 
spleen in, 290 
temperature in, 290 
tongue in, 702 
urine in, 294 
varieties of, 297 
Widal reaction in 233. See 

Serum diagnosis, 
without fever, 229 
without intestinal lesions, 298 
state, 199 
Typhus fever, 247 
Tyrosin crystals, in sputum, 528 
in urine, 953 



ULCER in mouth, 694 
of skin, diagnosis of, 144 

of stomach, 811 

sublingual, 695 

of tongue, 698 

trophic, 1008 
Umbilicus in tuberculous peritonitis, 728, 

755 
Unconsciousness, 64 
Uraemia, 956, 965 

asthma in, 461 

cardio-vascular symptoms of, 958 

dropsy in, 959 

dyspnoea in, 957, 965 

gastro-intestinal symptoms in, 965, 
977 

hemorrhage in, 959 

latent, 95» 

nervous symptoms in, 956, 965 

retinal changes in, 959, 965 

temperature in, 956, 965 
Urates in urine, 950 
Urea, estimation of, 920 
Ureters, catheterization of, 955 
Uric acid in blood, test for, 386 



1082 



INDEX. 



Uric acid diathesis, 184. See Gout. 

Neusser's granules in, 383 

in urine, 949 
Urine, acetone in, 936 

albumin in, causes of, 927 

quantitative estimation of, 926 

tests for, 921 
albumose in, 929 
alkapton in, 937 
bacteria in, 948 

bile-pigments and bile-acids in, 935 
blood in, 92S, 940 
cancer cells in, 949 
casts in, 941 
centrifugation of, 938 
chemical examination of, 919 
chlorides in, 920 

in gastric cancer, 794 

in pneumonia, 315 
cholesterin in, 954 
color of, 914 
cylindroids in, 945 
cystin in, 953 
diacetic acid in, 936 
entozoa in, 948 
epithelium in, 946 
extraneous matter in, 938 
fat and chyle in, 947 
in gastric disease, 794 
globulin in, 937 
indican in, 935 
leucin and tyrosin in, 953 
in lithsemia, 856 
melanin in, 954 

in nephritis, acute exudative, 961 
productive, 962 

chronic productive, 963, 964 
nucleo-albumin in, 928 
odor of, 919 
oxalates in, 952 
phosphates in, 950 
pus in, 936, 941 
reaction of, 918 
in rheumatic fever, 180 
sediments in, 918 

solids in, estimated from specific grav- 
ity, 918 
specific gravity of, 917 
spermatozoa in, 946 
sugar in, test for, 936 

quantitative estimation of, 932 
suppression of, 916 
urates in, 950 
urea in, 919 

quantitative estimation of, 920 
uric acid in, 949 
volume of, 914, 916 
Urticaria, 138 
Uvula, 710 



VALLE1X, points of, 
Valve-shock, 602 
Varicella, 253 



45 



Variola, 250 

varieties of, 252 
Varioloid, 252 
Vasomotor changes in hysterical joints, 190 

mechanism, 415 

symptoms in migraine, 50 
in neuralgia, 53 
Veins, diastolic collapse of, 601 

in adherent pericarditis, 649 

distention of, 598 

murmurs in, 641 

pulsation of, 599 

thrombosis of, 614 
Venous hum, 641 

pulse, 600 
Vertebral canal, aspiration of, 359 
Vertigo in dyspeptic headache, 52 

paralyzing, 109 
Vision, field of, 101 
Vocal resonance, 513 
Voice in adenoid disease, 715 

in central nervous disease, 449 
Volvulus, 843 
Vomiting, 764 

cerebral, 768 

cyclic, 768 

in gastric cancer, 767, 809 
ulcer, 767, 812 

in gastritis, 766 

in migraine, 50 

in peritonitis, 751, 768 

in phthisis, 561 

of pregnancy, 767 

reflex, 767 

in toxaemia, 768 

ursemic, 768, 957, 965 
Von Graefe's sign, 89 



WATERBRASH, 872 
Weight of body in disease, 76 
Weil's disease, 271 
Wernicke's sign, 104 
Whooping-cough, 265 
Widal reaction, 233. See Serum diagnosis. 
Williams' tracheal tone, 514 
Wintrich's change of note over cavity, 414 

in pneumothorax, 577 
Wool-sorter's disease, 278 
Word-blindness and word-deafness, 1000 
Wrist-drop, 113 
Writer's cramp, 1041 



XANTHELASMA, 695 
Xerostoma, 686 
X-ray examination of chest, 488 
of stomach, 775 



YELLOW fever, 303 

I bacillus of, 305 p 

general diagnosis of, 305 
serum diagnosis of, 305 



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